Healthy Volunteers - Imperial CRF

If you would like to hear from the Imperial Clinical Research Facility about studies you may be able to take part in, please complete this form.

We will then contact you when we have a study that you may be eligible for based on this information. Your details will be kept confidential, and you can ask to be removed from the database at any time.

If you are interested in being recruited for a specific study that you have seen advertised, such as our Ad4HIV vaccine trial, or have any questions please email imperial.recruitment.icrf@nhs.net or call 0203 313 8082.

Volunteer now

Name:
Email Address:
Telephone number:
Date of birth:
Gender:	FemaleMale
Height (please include units):
Weight (please include units):
Do you smoke?:	YesNo
Are you on any long-term regular medications? If yes, please enter their names:
Your ethnicity:
Where did you hear about us?:

With your permission, we will retain the above information in the Imperial CRF for an indefinite period of time. We will keep the information secure and treat it as confidential, so it will only be accessible to authorised staff, and researchers that are affiliated with the CRF. We will use this information to assess your suitability for research studies and to contact you about them. For more information about how we may use your data, please read our privacy statement at: http://imperial.crf.nihr.ac.uk/patients-public/.

If you wish to withdraw your consent to us using this information, you can do so at any time, and this does not mean you can’t participate in current or future studies. However once we have deleted your records, we will no longer be able to contact you about future research studies.

To withdraw your consent, simply email chris.rubery@nhs.net making it clear that you wish to have your details removed from the healthy volunteer database.

Please tick the box to indicate that you have read the above information, and you consent to us processing your information as described above and in the privacy statement.

All questions are optional except your name and one form of contact, however by providing other information we will be better able to identify more suitable studies for you.

Volunteer now

Name:

Email Address:

Telephone number:

Date of birth:

Gender:

Height (please include units):

Weight (please include units):

Do you smoke?:

Are you on any long-term regular medications?

Your ethnicity:

Where did you hear about us?:

Imperial CRF