To help us screen your patient and reach out if needed, please take a moment to complete the brief overview below. Your partnership in connecting patients with this research makes a real difference — thank you.

Referring Doctor Details

First Name: *

Last Name: *

Practice Name: *

Best Contact (email or phone):

Patient Details

First name: *

Last name: *

Date of birth *

Age

Best Contact Number: *

Email:

Patient Medical Information

Patients who meet any of the following criteria are potentially eligible for our current cardiovascular clinical trials.

Please tick all that apply.

Prior cardiac events: *

Myocardial Infarction (MI)StrokePercutaneous Coronary Intervention (PCI)Coronary Artery Bypass Graft (CABG)Amputation or significant peripheral arterial disease requiring revascularisationnone apply

High-risk factors: *

High calcium score >100High cholesterol on treatmentHigh LDL >2.59 nmol/LHigh Triglycerides >500 mg/dL (5 mmol/L)Known elevated Lp(a) >150 nmol/LHypertension, on medicationDiabetes Type 1Diabetes Type 2Current smoker/tobacco useFamily history of MI/PCI/CABG - parent or sibling <55 (if male), <65 (if female)none apply

I confirm the patient has not had cancer in the last five years (excluding skin cancer, prostate cancer (grade 1), cervical cancer (in situ)

Consent

By signing below, I confirm that the patient has been informed and consents to being contacted by Clinitrials regarding cardiovascular clinical trial screening and eligibility.

Signature:

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Date: *

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

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