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Firstname
*
Lastname
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Phone
Email Address
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Date of Birth
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Do you smoke?
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No
Past medical history?
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Medical History (If yes)
Please specify your past illness/injury.
Registration of trials in other clinical units:
*
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No
Registration of trials in other clinical units (If Yes):
If you choose Yes, Please write the name of other clinical units.
Trial History
*
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No
If you have participated in clinical trials before, please specify the place and date.
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Name Of The person who referred you
By registering your interest with Clineer Ltd., 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 Clineer Ltd 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 or directly via our Clineer Ltd app if you have downloaded and registered via the Clineer Ltd app.
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I hereby submit my personal information and consent the above.
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