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Prior To Submitting Your Information Please Read and Complete the Following
Authorization

1. I understand that I am going to be asked certain questions regarding my personal medical condition by TrialTech Medical, Inc. (“TrialTech”) personnel so they can determine my interest in a clinical research study. Initially, I will complete a questionnaire requesting limited information so that an initial evaluation may be made. TrialTech is assisting in the recruitment of eligible candidates for the CVL-865-PA-2001 (ADAPT) phase II clinical trial. See more information at https://clinicaltrials.gov/study/NCT05941442.

2. I agree to allow TrialTech and its personnel and associates, including telephonic screeners, to receive the personal information that I am solely for determining interest in potentially participating in the ADAPT clinical trial.

3. Except as allowed by me pursuant to this Authorization, TrialTech will not use, disclose, or sell my personal information or disclose my identity to third parties. TrialTech has taken reasonable security measures (based on HIPAA and other industry requirements) to protect my personal information disclosed on this site including secure servers, private data services, software encryption and others. Notwithstanding, TrialTech disclaims all responsibility for the protection of my personal information by the clinical research study site or other persons or entities who may gain access to my information. There is a possibility that once disclosed to the clinical investigator, privacy laws may no longer protect my information from being given to another person, class of persons, and/or companies.

4. I understand that, to the extent permitted by applicable law, once information that could be used to identify me has been removed and my information is no longer personally identifiable (i.e., connected to my identity), my de-identified personal information may be aggregated with de-identified information of others and used for research or business purposes.

5. No use of my personal information will reveal my identity without my separate specific written permission and authorization, or as otherwise required by applicable law.

6. I understand that I have the right to decline approval of this Authorization. If I refuse, TrialTech will not accept submission of my personal information and I will not be able to be evaluated by TrialTech for the ADAPT clinical trial survey. I understand that subject to review of this questionnaire and my Authorization, I may be contacted by TrialTech personnel to schedule a telephonic interview.

7. I understand that I may change my mind and cancel this Authorization prior to the time that my evaluation by TrialTech is complete. To cancel this Authorization, I must send an email to TrialTech at candidates@trialtechmedical.com stating that I wish to cancel. I have been advised to print a copy of this Authorization for my records. This Authorization has no expiration date.

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I agree