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Canadian Centre For Clinical Trials
Home
About CCCT
Current Trials
Contact Us
Register
News
Education
Diabetes
Gout
Medical News Bulletin
Clinical Trials Magazine Archives
Clinical Trials Magazine – Winter 2012
Clinical Trials Magazine – Spring 2012
Clinical Trials Magazine – Fall 2012
Home
Patients
Current Clinical Trials
Healthy Volunteers
Register
Register
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.
Note that our facility is located in Thornhill, Ontario. Therefore, please only register if you live in the GTA.
First Name
*
Last Name
*
Year of Birth:
*
Gender
*
Male
Female
City
*
Postal Code
*
Email
*
Phone
*
Do you have any medical conditions?
*
Yes
No
Do you have Diabetes Mellitus Type 2?
*
Yes
No
Do you have Cardio Vascular Disease (CVD) - Heart or Vessels Disease?
*
Yes
No
Do you have Hypertension (High Blood Pressure)?
*
Yes
No
Do you have Cerebro-Vascular-Accident (CVA) - Brain Stroke or Hemorrhage?
*
Yes
No
Do you have Migraines?
*
Yes
No
Do you have Gout?
*
Yes
No
Do you have Arthritis?
*
Yes
No
Do you have Fibromyalgia?
*
Yes
No
Do you have Chronic Pain?
*
Yes
No
Do you have Kidney Disease?
*
Yes
No
Do you have Thyroid Disease?
*
Yes
No
Do you have Anemia?
*
Yes
No
Do you have a history of alcohol abuse?
*
Yes
No
Do you have Obesity?
*
Yes
No
Do you have Male Sexual Health Problems?
*
Yes
No
Do you have Depression?
*
Yes
No
Do you have Allergies or Asthma?
*
Yes
No
If your medical condition is not in this list, please provide it 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:
Can we contact you in the future about studies that may pertain to you?
*
Yes
No
Please prove you are a real human being by typing the sequence below.
Name
This field is for validation purposes and should be left unchanged.
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