Registration for Healthy Volunteers

CANADIAN CENTRE
FOR CLINICAL TRIALS

Tel: (289) 597-0106 Email: info@clinicaltrialscanada.com view website for: professionals | patients

Healthy Volunteers

To register with our database, please complete the form below.

Providing us with this information will allow our research team to determine your eligibility for any of our current or future studies. Your information is kept strictly confidential and will only be used to notify you of studies that you have indicated an interest in.

*Name:
*Last Name:
*Year of Birth:
*Gender:
*City:
*Email:
Phone # (and best time to be contacted):
Do you have any medical conditions?	Yes No
* If yes, please list your medical conditions below:

*Are you currently taking any medication?	Yes No
*If you are taking medication, please list them below (name, dose & frequency):

*Do you have any history of smoking? Yes No
*If yes, provide details (years, number of packs/week):

*How did you hear about us? (Please be specific, i.e. Google search, Facebook ad, etc.)


If you would like to refer your friends, please list their email below. You will be compensated $50 for every referral that is successfully randomized into one of our trials:

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