How did you hear about this research study and phone number?
---Select One---
TV
Radio
Newspaper
Mail piece
Web or email
Someone told you
Other
What is your first name?
Which Country are you located?
---Select One---
United States
Canada
Which Province are you located in?
What is your last name?
What is your address?
What is your ZIP/Postal Code?
What is your home phone number?
What is your alternate phone number?
What is your email address?
What is your gender?
---Select One---
Male
Female
Other
(Female only) Are you post menopausal?
---Select One---
Yes
No
Unknown
(Female only) Are you pregnant, or planning a pregnancy?
---Select One---
Yes
No
(Female only) Are you currently using a contraceptive method or would you be willing to use a contraceptive to prevent pregnancy during this study?
---Select One---
Yes
No
Are you 18 to 65 years of age?
---Select One---
Yes
No
What is your height (inches)?
---Select One---
4'0"
4'1"
4'2"
4'3"
4'4"
4'5"
4'6"
4'7"
4'8"
4'9"
4’10’
4’11’’
5’0’’
5’1’’
5’2’’
5’3’’
5’4’’
5’5’’
5’6’’
5’7’’
5’8’’
5’9’’
5’10’’
5’11’’
6’0’’
6’1’’
6’2’’
6’3’’
6’4’’
6’5’’
6’6’’
6'7"
6'8"
6'9"
6'10"
6'11"
7'0"
what is your current weight (lbs)?
Do you have excess fat under your chin, which can also be called a double chin?
---Select One---
Yes
No
Unknown
Have you received previous treatment such as liposuction, to reduce the fat under your chin?
---Select One---
Yes
No
Within the past year, have you received any treatment such as laser procedures or chemical peels to your neck or chin area?
---Select One---
Yes
No
Over the past six months, have you maintained your current body weight?
---Select One---
Yes
No
Are you currently or do you plan to undergo a weight reduction plan in the next year?
---Select One---
Yes
No
Do you have any known conditions, such as claustrophobia, that would prevent you from having an MRI?
---Select One---
Yes
No
Have you participated in another clinical trial in the past 30 days?
---Select One---
Yes
No
If you pre-qualify for this study based on your answers you provided, may we contact you at the phone numbers you provided?
---Select One---
Yes
No
If no, how may we contact you?
If yes, which one?
---Select One---
Home Phone
Phone
Text
Alternate Phone
Both
Email
Which study location would you be willing to travel to?
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Study Location Results:
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