Form Test - Full - Simbec Orion

To enable us to make an assessment of your suitability for a Clinical Trial, we will first need to gather some personal details relating to your health. To ensure your suitability for a Clinical Trial, by ticking the checkbox you agree that the information you have provided is accurate to the best of your ability. Your personal data will be stored on our database which is only accessible by Simbec Research Ltd and our service providers. To aid in your suitability assessment, we will only share with companies that support us delivering our services. Under the current European Data Protection Laws (GDPR), you have a number of rights in relation to your personal data such as the right to access, right to rectification and right to be forgotten where appropriate. Please note: if you have not been contacted within 3 months of applying for a trial, please assume you are ineligible and that your data has been deleted from our system, if you believe you are eligible for another one of our trials, please apply again in 3 months.

For more information regarding our commitment to your privacy, please read our Privacy-Policy

Agreement(Required)

I understand the above and wish to proceed

Do you regularly use substances that are used for non-medicinal and leisure purposes. We test as part of the screening assessments for all our trials?(Required)

Yes

(A urine sample will be collected for drugs of abuse testing at screening (Alcohol, amphetamines, barbiturates, benzodiazepines, cannabinoids/tetrahydrocannabinoids (THC), cocaine, methadone, and opiates etc)

Thank you for your time and interest, but unfortunately based on your answer, you would be unable to join our panel at this time. But please feel free to re-apply if your circumstances change or keep a lookout for future clinical trials, we will be recruiting for which you may be eligible and able to participate

Why are you submitting a general application today?

First Name(Required)

Surname(Required)

Phone Number(Required)

Email(Required)

Gender(Required)

Date of Birth(Required)

Height (cm)(Required)

Weight (kg)(Required)

Have you previously participated in a trial at Simbec-Orion?(Required)

Yes

Are you registered with a GP ?:(Required)

Yes

(must be a UK resident for at least 1 year)

How long have you been registered there?:(Required)

Are you taking any prescribed or repeat medication from a GP or a chemist?:(Required)

Yes

Please state medication:(Required)

Do you suffer from or ever had any serious illnesses as diagnosed by your GP or health professional?:(Required)

Yes

Please state diagnosed condition or illness(Required)

Have you taken part in a clinical trial in the last 90 days or 3 months?:(Required)

Yes

Have you donated blood in the last 3 months?:(Required)

Yes

Are you a smoker?(Required)

Yes

(if you are a dual user of both normal cigarettes and e-cigarettes please complete both fields below)

Do you use Cigarettes – if yes, how many per day?

E cigarettes – If yes, what strength per day?

Do you drink alcohol?:(Required)

Yes

How many units per week?:(Required)

Have you had any body piercings or tattoos in the last 3 months?:(Required)

Yes

Are you currently using a form of contraception ?:(Required)

Yes

What type of contraception do you use?:(Required)

Where did you hear about us?(Required)

This field is hidden when viewing the form

How would you like us to contact you?(Required)

pick one!

This field is hidden when viewing the form

What is your preferred time to be contacted?(Required)

pick one!

Form Test – Full

Generic Application (Test – Full Open)

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