Form Test - Multipage - Simbec Orion

Step 1 of 3 – Agreement

* indicates a required field

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*

I understand and wish to proceed

Do you regularly use substances that are used for non-medicinal and/or leisure purposes?*

Yes

We test as part of the screening assessments for all our studies.

Thank you for your time and interest, but unfortunately based on your answer, you are not eligible to register at this time.

Please select the below option that best describes you*

* indicates a required field

First Name*

Surname*

Phone Number*

Email*

Gender at Birth*

Date of Birth*

Hidden

Today

Hidden

Age

Thank you for your time and interest, but unfortunately based on your answer, you are not eligible to register at this time.

Height*

Weight*

Your BMI

Hidden

BMI Calc

Thank you for your time and interest, but unfortunately based on your answer, you are not eligible to register at this time.

Have you previously participated in a trial at Simbec-Orion?*

Yes

Where did you hear about us?

Form Test – Multipage

Main Registration

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