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Register for clinical trial Neurologische Störungen

With this form you register yourself for this trial. Your registration is completely without obligation. When you register, our team will review your information. Call ICON to discuss your registration for the trial and further pre-screening.

Sie müssen Englisch oder Niederländisch sprechen, verstehen und lesen können, um an einer Studie teilnehmen zu können.

Previously registered at ICON?

Yes
No

Name

First name*

First name*

Preposition

Preposition

Last name*

Last name*

Gender*

Male
Female

Date of birth

Day*

Day*

Month*

Month*

Year*

Year*

Address

Enter your address here.

Enter your address here.*

Street name*

Street name*

House No.*

House No.*

Postal code*

Postal code*

City*

City*

Country*

Country*

Contact details

Telephone number*

Telephone number*

Telephone number (optional)

Telephone number (optional)

E-mail address*

E-mail address*

I would like to be kept informed about potentially suitable trials via

Email

Email

SMS

SMS

Yes, I sign up for the general newsletter, which I receive a maximum of 4 times a year

Yes, I sign up for the general newsletter, which I receive a maximum of 4 times a year

Do you smoke?*

No
Yes

How much do you smoke? Select tobacco consumption

How much do you smoke? Select tobacco consumption

Do you have a medical condition?*

No
Yes

What medical condition(s) do you have and medicines do you use?

What medical condition(s) do you have and medicines do you use?

Are you currently under the treatment of a doctor?*

No
Yes

Please state why you are under the treatment of a doctor.

Please state why you are under the treatment of a doctor.

Length and weight

Height (in cm)*

Height (in cm)*

Weight (in kg)*

Weight (in kg)*

BMI

Do you have a question or comment?

Do not provide additional sensitive or medical personal information here.

Do not provide additional sensitive or medical personal information here.

Data protection

ICON plc is the data controller of the personal data, including health data, you choose to provide. We rely on your consent to use this information to identify potentially appropriate clinical trials for you and contact you about them.

You can withdraw your consent at any time, for example by contacting us through our contact form or by telling a member of our recruitment team when speaking with them.However, the processing of your information before withdrawing your consent remains lawful.

Additional information on how your data will be processed and how you can exercise your rights, can be found in our Privacy Policy.

Please confirm if you consent to ICON plc collecting and using your personal data for the above purposes. *

I agree*

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You will receive a confirmation of your registration at the specified e-mail address.

Name

First name*

First name*

Preposition

Preposition

Last name*

Last name*

Gender*

Male
Female

Date of birth

Day*

Day*

Month*

Month*

Year*

Year*

Contact details

Telephone number*

Telephone number*

Telephone number (optional)

Telephone number (optional)

E-mail address*

E-mail address*

I agree*

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Reasons to participate:

1.

No new medicines without clinical research

New or better medicines are crucial to all of us, but even more so to patients who rely on medicines.
2.

You receive a nice reward

We offer you a nice compensation for your contribution!
3.

Time to relax, work or study

While you are at the research center you have time for yourself. Make it useful or use the time just to relax!
4.

Have fun together

You can do all sorts of things in the research center: play a game with others or enjoy gaming.

Was sind Arzneimittelstudien?
Wie funktioniert es?
Sind Arzneimittelstudien sicher?
Vergütung
Fakten und Mythen

Erfahrungsberichte
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Registrieren bei ICON

info@iconarzneimittelforschung.de

0800-0292044
Aus Belgien: 0800-89036
Aus Deutschland: 0031-50-8505798

Montag bis Freitag

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08.30 bis 5.00 Uhr

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