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I confirm that the name and contact information set forth above is my name and contact information or that I am submitting the form on behalf of an individual who has legally authorized me to submit this request; (2) the personal information I provide in this form may be used by Accel Research Sites, and its affiliates, partners, and medical professionals in connection with considering my potential participation in clinical research studies; (3) I am requesting that Accel Research Sites contact me using the information I have provided on Accel Research Sites’ website; and (4) I have read and understand Accel Research Sites’ Privacy Policy.

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