Clinical trial screening

Thank you for your interest in our clinical trial program. Please provide as much information as you are able to. The information provided will help our clinical trial coordinators determine which clinical trial would be most beneficial to you.

If you have any questions, please email clinicaltrials@perimaneyeinstitute.com

Name*

First NameLast Name

Date of Birth*

Date

Email*

You will be added to our email database using MailChimp.com

Phone Number*

Please enter a valid phone number.

Phone number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you currently being treated for dry eyes?*

Please answer the following

	Yes	No	N/A
Have you been diagnosed with dry eye disease by an ophthalmologist or optometrist?
Are you currently using Xiidra, Cequa or Restasis?
If you are currently using Xiidra, Cequa or Restasis, have you been using it continually for 6 months or more?
Are you currently using OTC artificial tears, gels or ointments for dry eyes?
Are you currently using Rx eye ointment for dry eyes?
Are you currently using a steroid eye drop, gel or ointment to treat dry eye?
In the past 6 months have you used a steroid drop, gel or ointment to treat dry eye?
Do you wear any contact lenses?
If you wear contact lenses, are you able to stop wearing them for the duration of a clinical trial?
Have you had LASIK or PRK?
Do you have a history of stye/chalazion?
Do you have any history of herpetic keratitis, ocular herpes simplex or ocular herpes zoster?
Are you currently using any Rx eye drops to treat glaucoma?
Are you currently using Latisse?
Are you currently using any eyelash growth serum or lash extensions?
Have you been prescribed topical or systemic antibiotics or topical steroids to treat blepharitis in the past 30 days?
Do you have any history of Steven's-Johnson syndrome or advanced Anterior Basement Membrane Dystrophy?
Have you had Lipiflow in the past 6 months?
Have you used ocular topical or facial steroids, oral Doxycycline or oral Tetracycline in the past 30 days?
Are you currently pregnant or breastfeeding? (Female patients of child bearing potential will need to use an acceptable means of contraception during a clinical trial and will need to be willing to submit a urine pregnancy test before enrolling in and additionally throughout a clinical trial based on the trial protocol.)
Have you ever had eyelash extensions or use eyelash growth serum?

Approximate date your dry eye was diagnosed.

Is your dry eye self reported or diagnosed by an ophthalmologist or optometrist?

What is your current dry eye treatment:

What dry eye treatments have you previously tried:

Please list all Rx and OTC medications you are currently using including name, dose and frequency:

You can upload a current list of your medications if you prefer:

Our clinical trial days are generally on Wednesday and Thursday. Please provide some general availability notes:

Is there any additional information you would like to share?

Thank you for taking the time to provide this valuable information about your dry eye history. Once our clinical trial coordinators have reviewed the information you have provided, you will receive an email with scheduling information.

If our current clinical trials are not a good fit, there may be another opportunity in the future. We will keep this information on file and contact you with future clinical trial opportunites.

We appreciate your interest and look forward to working with you!

Clinical Trial Screening