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Register Interest
Participants
Participate
Current Trials
NZCR Screening HQ
Payment Forms
FAQ’s
Sponsors
Why NZCR?
Our Expertise
Our Facilities and Services
About Us
About NZCR
Meet the Team
News
Current Trials
Register your Interest
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Registration Form
Thank you for your interest - you can register with us using the form below. Our team will be in touch with you as soon as your profile matches one of our trials.
First name
(Required)
(as shown on identification document e.g. Driver's License, Passport)
Middle name
(as shown on identification document e.g. Driver's License, Passport)
Last name
(Required)
(as shown on identification document e.g. Driver's License, Passport)
DOB
(Required)
MM slash DD slash YYYY
Biological sex
(Required)
--
Male
Female
Height
(Required)
in cms
Weight
(Required)
in kgs
Ethnicity
(Required)
--
NZ European
Other European
Māori
Tongan
Niuean
Samoan
Cook Island Māori
Other Pacific Islander
Indian
Chinese
Japanese
Korean
Other Asian
Middle Eastern
Latin American
African
Other
Why do we need this information? We are required to follow FDA guidance on the collection of Race and Ethnicity Data in our Clinical trials.
Which region do you currently live in?
(Required)
--
Northland
Auckland
Waikato
Bay of Plenty
Gisbourne
Hawke's Bay
Taranaki
Manawatū-Whanganui
Wellington
Tasman
Nelson
Marlborough
West Coast
Canterbury
Otago
Southland
Have you been vaccinated against Covid-19?
(Required)
--
Yes
No
Contact Details
Mobile Phone
(Required)
Home Phone
Email
(Required)
Trials Interested
Preferred Location
(Required)
--
Auckland
Christchurch
Hamilton
Wellington
Trials Interested (Optional)
Medical & Demographic Details
Are you currently on any medication?
(Required)
--
Yes
No
If Yes, please select the Medications
(Required)
Vitamins and Supplements (including Protein powder)
Allergy medications
Inhalers
Topical Creams
Anti-Depressant medications
Blood pressure medications
Blood thinning medications
Diabetic medications
Heart medications
Thyroid medication
Other
If Other, please specify
(Required)
Have you ever had an allergic reaction to any drug or food?
(Required)
--
Yes
No
If Yes, please specify
(Required)
Do you have/had any Medical Conditions?
(Required)
--
Yes
No
If Yes, please select the Medical conditions
(Required)
Asthma
Cancer
Diabetes
Epilepsy
Hepatitis
Other Liver problems
Rheumatoid Arthritis
Mental health condition
Skin condition
High Cholesterol
High blood pressure
Coeliac disease
Gastrointestinal problems
HIV
Cold sores
Other conditions
If Other, please specify
(Required)
Smoking/Vaping history
(Required)
--
Smoker
Non-Smoker
Ex-Smoker
Vaper
Marketing Question
How did you hear about us?
(Required)
--
LinkedIn
Email
Facebook
Instagram
Other Social Media
Family/Friends
Events
Flyers/Posters/Billboards
Radio
Job Sites
GP/Specialist Referral
Bus Ad
Google Advertising
Others
Privacy Policy
I understand that by submitting this form, NZCR will hold the information above in a database. All information provided is confidential and will not be given or sold to any other agency without prior consent. I also understand that by submitting this form, I will be receiving emails, texts or calls about potential studies which I can unsubscribe from at any time. For more information, please refer to the
Privacy Policy
(Required)
I consent to this
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