MEDPED Email Registration Form

This information is considered confidential and will be kept in secure files at the MEDPED Coordinating Center at the University of Utah School of Medicine.

This form will be transmitted SECURELY, using encryption, to keep your information confidential over the internet.

Name:

Home Phone Number (with area code):

Work Phone Number (with area code):

When is the best time to reach you:

Email Address:

Address:

City:

State:

Zip:

Country:

Date of highest cholesterol test:

Your age at the time of your highest cholesterol:

Please list the following levels at the time of your highest cholesterol test:

Total cholesterol level:

Triglyceride level:

HDL level (good cholesterol):

LDL level (bad cholesterol):

Feedback:

        

University of Utah Salt Lake City, UT 84112 801- 581-8720
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