LifeDNA | The COVID-19 Human Genetics Study

First Name:

Last Name:

Email:

Age:

Phone Number:

● Gender:

Male

Female

● Have you been tested for COVID-19?

Yes

Are you currently taking any of the following supplements daily or almost daily?

Vitamin C

Less than 90 mg

At least 90 mg

Vitamin D

Less than 600 IU/15 mcg

At least 600 IU/15 mcg

Vitamin E

Less than 15 mg

At least 15 mg

Zinc

Less than 11 mg

At least 11 mg

Selenium

Less than 55 mcg

At least 55 mcg

● Are you currently taking any multivitamin?

Yes

If yes, what is the brand and how frequently do you take it? (e.g. Centrum Advance, 1/day), If no type none:

● My DNA sample may only be stored and used for future research that relates to the clinical area [COVID] being investigated under this study. Choose one:

Yes

● My specimens may be stored and used to support any future research. Choose one:

Yes

● I will consider providing consent to use my DNA sample to support future research. Prior to any future research use, please provide me with a consent form that describes the protocol.

Yes

● My DNA sample may be stored and used for the development of commercial products without any financial compensation to me. Choose one:

Yes

Please read the informed consent document here and check the boxes below to participate in the study:

I am between 18 and 60 years old today.

I give my consent to take part in this research study and agree to allow my DNA analysis (genotyping) results to be used for scientific research as described on the consent document.

I consent to using my personal data (including without limitation, the data I provide relating to my health) for research as set forth in this consent.

I have read the consent document.

This research study has been sufficiently explained to me, including risks and possible benefits (if any), other possible treatments or procedures, and other important things about the study.

I have had the opportunity to ask questions.

I understand the information given to me.

●I give my consent to this research.

Yes