Woolcock Institute of Medical Research
Search
Home
About Us
Research Groups
Foundation
Clinic
Studies
Education
News & Events
Publications
Contact Us
Test Page
Sleep Apnea cardioVascular Endpoints
Development of the Stage Of Change Scale Specific
Development of the short-form Inhaled Corticostero
Courses
Registration
Secure SSL Certificate
Introduction
Epidemiology Services
Woolcock Shop
Your Cart
Refund Policy
Take part in a research study
What are research studies
Your rights as a participant
Advantages of participating
Your responsibilities as a participant
Main risks of participating
Register for studies
Current Research Studies
Sleep apnea and cardiovascular disease
Sleep Disturbances with Asthma & Rhinitis Form
COPD Screening Form
Research Projects
PhD
Honours
Summer Research Projects
Masters
Sleep Honours / Masters
Donate Now - As a not-for-profit organisation we relies on your generous support to continue our vital medical research. Find Out more\
Search
Research Database Consent Form
Would you like to participate in our medical research?
If your answer is YES, please complete your details below.
If your answer is NO, please leave this form blank.
Yes
No
THIS CONSENT IS VOLUNTARY AND YOU ARE UNDER NO OBLIGATION
I DO consent for my details to be added to the Woolcock Institute of Medical Research Volunteers Database regarding potential participation in clinical trials for medical research. My participation in clinical trials is voluntary and I am under no obligation to participate.
Surname:*
First name:*
Birthday*
Address:*
Suburb:*
Postcode:*
Phone numbers:*
Email:
Gender: (please select)
Female
Male
Have you been diagnosed with, or think you may have? (please check for each)
OSA (obtrusive sleep apnea)
RLS (restless legs syndrome)
Asthma
Insomnia
Bronchiectasis
Allergic rhinitis
Narcolepsy
Healthy Volunteer
Other lung disease
Shift worker
COPD (emphysema/chronic bronchitis)
Are you diabetic?
No
Type I
Type II
Do you have high blood pressure?
No
Yes
Height:
Weight:
Smoking status:
Never
Past
Current
Please select
Are you a shift worker?
Yes
No
Have you received any treatment for a sleep disorder?
If so please state what kind of treatment
Do you currently take any medications?
If so, please state which medications
I agree to receive mailings from the Woolcock Institute of Medical Research.
Date
Submit
* Required
Click here
for research study participant privacy statement
Research Studies
Seeking participants
Are you expecting your first baby?
Do you have high blood pressure and snore?
Do you have sleep apnea?
Do you have COPD?
Nightshift Study
Adolescent Study
Tablet for asthma?
AMAZES
Insomnia sleep study
Can't use CPAP or MAS?
List of Studies
Donate
Credit Card Processing
Payment Gateway
E-Commerce
WEB DEVELOPER