NZCR Auckland Registration Form

To complete your registration, please answer the following questions. The information you provide will help us know what trials you might be eligible for

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Personal Details

(as shown on identification document e.g. Driver's License, Passport)

First name*

Middle name

Last name*

How did you hear about us?*

Biological sex*

Clinical Study

NZCR site*

Contact Details

Email*

Phone*

Region*

DOB*

Height (cm)*

Weight (kg)*

Ethnicity*

Medical History

Are you currently on any medication?*

If yes, please select below

Others, please specify:

Have you ever had allergic reaction to any drug or food?*

Do you have/had any of the following conditions?*

If yes, please specify

Others, please specify:

Smoking/Vaping history*

Have you been vaccinated against Covid-19?*

Privacy Policy

I understand that by submitting this form, NZCR will hold the information above in a database. All information provided is confidential and will not be given or sold to any other agency without prior consent. I also understand that by submitting this form, I will be receiving emails, texts or calls about potential studies which I can unsubscribe from at any time. For more information, please refer to the Privacy Policy

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Medical History

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About NZCR

Auckland

Christchurch