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Clinical Trial is conducted to investigate the effects of new treatments in human volunteers. Participating in a clinical trial can help contribute to potential new treatment in human, which would benefit the public. If you are interested in future clinical trials, please complete the following questions:
1. Do you have any
pre-existing
medical conditions?
Yes
No
Please Specify
*
2. Are you
currently
on any medication? If yes, please indicate:
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*
3. Do you have any
drug allergy
?
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No
Please Specify
*
4. Have you participated in any clinical trial
before
?
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No
Please Specify Completion Year
*
5. Are you
currently
participating in any clinical trial?
Yes
No
Please Specify Trial Name
*
6. Are you
currently
pregnant or breastfeeding?
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7. Can we
contact
you for future studies?
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I attest that the information I have provided is accurate and complete to the best of my knowledge. By filling and signing this form, I consent to the collection, use and storage of the above information by Singapore General Hospital, Clinical Trials and Research Centre. This information will be kept confidential as per institution's policy.
I acknowledge I have read and understood the statement above
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11/27/2018 12:39 PM
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