Register for a trial

Nucleus Network conducts a variety of different clinical trials throughout the year. By filling out the following registration form, you will enable us to enter your details onto our secure recruitment database/mailing list. The database is treated with the utmost confidentiality and your information will only be used for the sole purpose of recruitment. This means that we will be able to forward you information about current and upcoming studies in which you may be interested either by email, post or telephone.


First Name:               Second Name:             
Last Name:
Gender:
Nationality:               Ethinic Background:  
Postal Address:
Contact Details:                    Mobile:           Home:           Work: 
Email Address:
Date of Birth:                Country of Birth:         
Height:                Weight:                         
Do you have any medical conditions? Yes No
If 'Yes' please specify:
Do you take any medications? Yes No
If 'Yes' please specify:
Do you smoke? Yes No
If 'Yes' please specify
how many per day and week:
If not currently smoking have you
smoked in the last 12 months?		 Yes No
If “Yes” please specify whether as a
social smoker only or no of years smoked:

Do you have Asthma? Yes No
If not a current asthmatic, do
you have a past history of Asthma? 		Yes  No
If 'Yes' please specify:
Have you had any operations? Yes No
If 'Yes' please specify:
Do you have any
allergies/anaphylactic reactions?		 Yes No
If 'Yes' please specify:
Do you have any dietary restrictions? Yes No
If 'Yes' please specify
the type of dietary restrictions:		 Vegan Vegetarian Halal No Pork Other
How did you hear about The Centre for Clinical Studies?
TV Radio Newspaper Friend Online Magazine Flyers Other
Please provide any further
information you would like to add: