Register Interest

Personal Details
(as shown on identification document e.g. Driver's License, Passport)
Name*
First Middle Surname
DOB*
Ethnicity*
Gender*
- Male
- Female
Height*
Please enter a value between 0 and 3.
(metres eg: 1.77)
Weight*
(kilograms eg: 85)
BMI
(automatically calculated from height & weight)
Contact Details
Street Address*
eg 13 Summer Street
Suburb*
City*
Postcode*
Mobile Phone*
Home Phone
Work Phone
Email*
Marketing Question
How did you hear about us?*

We have two types of trials available. You may select ONE.
1. Healthy volunteer trials are for people who are physically fit and healthy
2. Patient trials are for people with certain diseases i.e. Alzheimer's, cancer, hepatitis, HIV...
Are you interested in receiving information about:*
- Healthy volunteer trials (no further questions)
- Patient trials (additional info required)
Family Doctors
Doctor's Address
Doctor's Phone
Doctor's Fax
Employment Status
Employment Status*
- Work Full-Time
- Work Part-Time
Smoking History
Smoking Status*
- Non-smoker
- Previous Smoker
- Smoker
Years Last Smoked*
Cigarettes per day*
Medical History
List of all known allergies
(including drug and food allergies)
List any known medical conditions:
(eg. diabetes, cancer, migraine, asthma, high blood pressure, etc.)
List any medications that you take regularly
(including herbal remedies, supplements or any contraceptive therapy)
List conditions that medications are used for
Have you ever had any of the following? (Please indicate and include year of procedure)
Hysterectomy (indicate year if relevant)
Tubal Ligation (indicate year if relevant)
Vasectomy (indicate year if relevant)
If you have ever participated in a clinical trial before, please indicate the year below
Year of Prev Trial
Where was your previous trial?
(If relevant)
Privacy Policy
ACS will hold the information above in a database and I understand this information will remain confidential and only to be used by ACS.*
- I consent to this

Personal Details