Registration - Chinese Medical Research

Firstname *

Lastname *

Phone

Email Address *

Street Address

Apartment, suite, etc

City

County

Postal Code

Country

Sex *MaleFemale

Date of Birth *

Height in cm *

Weight in kg *

Do you smoke?YesNo

Past medical history?YesNo

Medical History (If yes)Please specify your past illness/injury.

Registration of trials in other clinical units: *YesNo

Registration of trials in other clinical units (If Yes):If you choose Yes, Please write the name of other clinical units.

Trial History *YesNo

If you have participated in clinical trials before, please specify the place and date.

Name Of The person who referred youA Friend

Please specify the event or fair you had taken partEvent or Fair

Name of Content CreatorContent Creator

Please specify newspaperNewspaper

Please specify websiteOnline Advertisement

Please specifyOther

By registering your interest with Chinese Medical Research, You agree for our company to retain your data within our subject / participant database in complete confidence and protected by UK Data Protection Act, General Data Protection Regulation (EU) 2016/679 and all applicable USA / global data protection laws. You are agreeing to Chinese Medical Research using this information to contact you for clinical studies you may eligible for. You are agreeing that your information may be shared with other Clinical Research Units which are conducting clinical studies which you are interested in. You are agreeing that your information can be sent to the Clinical research units in advance of your screening visit, as part of booking you an appointment for study specific medical screening process. The information will be securely stored on the Clinical Research Unit volunteer database in Europe or Non-EU country (e.g. USA) Please note that this data will not be shared with any third party without your permission therefore in order to register you onto our database we require your consent and permission to share your information in confidence, as stated above. We will only share your information with Clinical Research companies / clinics conducting studies which you are wishing to participate in. You may obtain your record or request to delete by writing to us via email. *I hereby submit my personal information and consent the above.

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