Register your interest Please complete the registration below Please read our Fusion Clinical Research Privacy Policy Register Your Interest In Trial Participation Use this form to register your interest in participating in clinical research trials with Fusion Clinical Research. "*" indicates required fields Name* First Last Email Address Phone Number* We will use this number to contact your about upcoming studies. Postal Code* Sex* Male Female Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Height (cm)* Weight (kg)* Race*Choose your raceAboriginalAfricanAsianCaucasianMiddle EasternOtherOther Do you drink alcohol? Yes No Quantity of standard drinks / day Are you a smoker? Yes No Quantity per day (cigarettes) Do you have an allergy to any food or medications? Yes No If so, please specifyDo you take any medication on a regular basis? Yes No If so, please specify Females only: Are you either post-menopausal or surgically sterile? Yes No If 'yes'Post-menopausalSurgically SterileTubal LigationIf 'no', are you currently taking a form of contraception? Yes No If 'yes'PillImplantInjectionIntrauterine DeviceRegular or most recent Doctor/Medical Centre DetailsDo you suffer from or have a history of any of the following? Hepatitis B, C, or HIV Mental Illness Asthma Epilepsy Diabetes Type 1 Diabetes Type 2 Kidney Disease Liver Problems Osteoarthritis Rheumatoid arthritis Psoriasis Gastrointestinal Disorders High Blood Pressure High Cholesterol Heart Condition Eczema Cancer Other If 'Cancer', pleae specify If 'Other', please specify * I agree for my information to be entered in the Fusion Clinical Research database for future contact * I have read and understood Fusion Clinical Research's Privacy Policy * There is no photography of any description allowed in the Fusion Clinical Research unit. I agree not to take any photos at all within the Fusion Clinical Research unit CAPTCHA
