General Information

Any personal information you share in this form will be stored securely and kept strictly confidential in accordance with Australian privacy laws and regulations.

First name *

Surname *

Date of birth *

Age

Gender *

MaleFemaleOtherPrefer not to say

Email *

Best Contact Number *

Address Details: *

Street address

City *

Postcode *

Health History

The following questions about your health will help inform our clinical team of your potential eligibility for current and future trials. We appreciate you help by completing this section of our questionnaire to the best of your ability. The information you share in this section of the form will be stored securely and kept strictly confidential in accordance with Australian privacy laws and regulations.

Pleasse specify your condition *

Please let us know what medication(s) you are taking: *

Consent

I have read and agree to the Clinitrials Privacy Policy and I consent to being contacted by Clinitrials about trials I may be eligible for. *

By signing below, I confirm the above information I have provided is true, complete and accurate to the best of my ability.

Signature

Draw signature|Type signatureClear

Date *

Your information is stored securely and will only be used to assess your eligibility for Clinitrials studies.

Save and Complete Later