UMN-Hatsukami-Smoking2 - Screening Form

Screening Form

Please complete the screening form below

First Name

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Last Name

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Phone Number

Email Address

Date of Birth

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How many cigarettes do you smoke a day?

Which brand of cigarettes do you usually smoke? Please be specific about your brand type (ie Marlboro Reds regular length or Newport Menthol 100s green box)

You agree that BuildClinical may provide your personal information to the research site to help determine if you are eligible for this study. Please refer to BuildClinical's Terms of Service and Privacy Policy for more information.

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Screening Form

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