I would like to participate in the study SIM-33819.

Thank you for your interest in joining our panel of healthy volunteers, please register by completing the on line questionnaire. If you are suitable, a member of our Volunteer Recruitment team will contact you to discuss the next step in joining our panel of healthy volunteers. Alternatively, please contact Volunteer Recruitment on Free phone 0800 691995 with any questions or to discuss any queries you may have. Thank you.

First Name : *

Middle name:

Surname: *

Gender: *

Male

Female

Date of birth: *

Email: *

Mobile No:

Daytime telephone: *

Address:

Country: *

Postal: *

To enable us to make an assessment of your suitability we will need to ask you some personal details and health related information to assess your suitability for each clinical trial. This information will be held on a database and will only be used by Simbec Research Ltd to assess your suitability and will only be shared with companies that support us delivering our services. Under existing Data Protection Laws, you have a number of rights in relation to your personal data such as right to access, rectification and erasure where appropriate.

Do you wish to proceed?: *

Body Mass Index ?The Body Mass Index targeted is approximative and is subject to change. :

feet

Height: '

Height: m

Weight:

Minimum:
Males 9st 6lb
Females 8st

pounds

BMI:

Smoking habits: *

Smoker

Non-smoker

How many cigarettes per day?:

Less than a year

More than a year

Do you use any recreational drugs?:

Yes

(we test as part of the medical)

Are you a regular blood donor?:

Yes

(must not have donated in the last 3 months)

Do you drink?:

Yes

How many units per week?: units

Have you had any body piercings or tattoos in the last 6 months?:

Yes

Female Volunteers

Are you currently using some form of contraception - using it for 3 months?:

Do you have a child less than 1 year old?:

What type of contraception do you use?:

Have you had a smear test in the last 3 years and was it normal?:

Comments or other specifications:

Fields marked with an asterisk are mandatory.

Confidentiality

Simbec follows very rigorous personal information protection and safety policies and practises in accordance with the UK Data protection Act 1998.

Learn more

Why so many questions

Have questions about our clinical trial study process? See answers to commonly asked questions.

Learn more

	SIM-33575 Up to £3500
	SIM-33819 £2720
	SIM-34233 £1395

Volunteers

Give us a call

Simply contact one of our recruitment staff who will be happy to take you through the initial process of joining our panel of volunteers.

0800 691995

Apply now