Clinicontact Example Form

Full Name

Email Address - Format validation

Phone Number - Country and format validation

Date of Birth - Older than 18 and format validation

Format: Month/Day/Year (e.g., 01/15/2000)

City and State

Contact for future studies?

Yes No

What types of studies would you be interested in?

List comma separated keywords

How do you prefer we contact you?

Text Email Phone No preference

Do you currently live in the United States? (This also shows an example of us placing images on questions)

Yes No

Click image to open enlarged version

Select an option to show different fields?

Option 1 Option 2

Option 1 selection: Checkbox: Does your child have any of these medical or psychiatric conditions? Check all that apply

Primary psychiatric diagnosis other than ADHD Major neurological disorder Global developmental delay Intellectual disability Significant systemic illness None of the above

Option 1 and 2: Another to be shown

Option 2 to be shown

🎉 You're all set — here's what happens next

Thanks for taking the time to complete this screener! Our CliniContact sales team will be in touch shortly to walk you through the details, answer every question you throw at us, and make sure you have everything you need to move forward with confidence.

Expect a friendly outreach via your preferred contact method — no pressure, just real humans ready to help.

✅ Personalized guidance from a real team member
✅ Clear next steps tailored to your situation
✅ Answers to any questions, big or small