1 Step 1 Your details2 Step 2 Trial details Personal Details(as shown on identification document e.g. Driver's License, Passport)Name* First Surname DOB* Gender*MaleFemaleRace*WhiteBlackPacific IslanderMaoriChineseJapaneseOther AsianMiddle EasternLatin AmericanAfricanOtherFDA Guidance for Collection of Race and Ethnicity Data in Clinical TrialsContact DetailsMobile Phone*Email* Marketing QuestionHow did you hear about us?*--Social mediaRadioJob websiteWebsiteFriend (word of mouth)Noticeboard/FlyerSkykiwiStuffOther We have two types of trials available. You may select ONE. Healthy volunteer trials are for people who are physically fit and healthy 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 DoctorsDoctor's AddressDoctor's PhoneDoctor's FaxEmployment StatusEmployment Status*Work Full-TimeWork Part-TimeSmoking HistorySmoking Status*Non-smokerPrevious SmokerSmokerYears Last Smoked*Cigarettes per day*Medical HistoryList 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 belowYear of Prev TrialWhere was your previous trial?(If relevant)Privacy PolicyACS 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
