Clinial Trial Questionnaire
 

Are you interested in clinical trials and do you want us to contact you should you qualify for a study?  If your answer is YES, please complete the form.

Your information will stay confidential and will be used by the staff of JOHESE only for approved clinical trials.

  * Fields are mandatory
  * Please complete the fields below or alternatively complete the MEDICAL HISTORY Survey
     
  Name:
  Surname:
  Age:
  Gender:
  Contact Nr:
  Email:
     
  Address:
   
 
   
  * Current chronic diseases:
   
 
   
  * Current medication:
   
 
   
  * Are you willing to travel to the Midstream in Centurion?
     
  Yes
  No
   
  * Are you willing to participate in a study should there be a study available?
     
  Yes
  No
   
  Any other comments or questions: