covance

test with the best

  

United Kingdom


If you are already registered on our database and are interested in taking part in one of our studies, please telephone us on 0800 591570 or email us at leeds.volunteer@covance.com and a member of our volunteer recruitment team will call you back. For new volunteers, please complete the following form.


INFORMATION
Note: Bold fields are required

Select Location:

Study No:




Title:

First Name:

Middle Name:

Last Name:

Address Line 1:

Address Line 2:

City:

Postcode:

County:

Home Number:
 

Mobile Number:
 

Daytime Number:
 

Email Address:

Date of Birth:
- -
dd,mmm,yyyy i.e., 01, Oct, 2009

Ethnicity:
National Insurance Number:


Gender:
Employment Status:
Height:
 Feet  Inches

Weight:
 Stones  Pounds 

BMI Calculation:

Do you smoke:

If yes, how many cigarettes per day?





Ladies Only:

Are you surgically sterile ?

Are you post-menopausal?

Do you use contraception?


Do you have any current/ongoing medical conditions?



How did you hear about us?


Are you registered with a GP in the UK who holds your last 3 years medical history?





Security Code:

Enter Code:



The information which you submit will be held by Covance Clinical Research Unit Limited (Covance) for the purpose of processing your application for entry into a clinical trial.

Covance will also obtain a medical report and a separate consent form will be posted out to you once your application has been processed. Information from this medical report may be held on paper and on a computer database. All information will be retained by Covance and may be shared between other companies in the Covance group of companies, which may involve transfer of this information outside of the European economic area. Parts of your data may be disclosed to the organisers of any clinical trial that you may be involved in and to the regulatory authorities. However your name will not appear on the documents generated by Covance during the clinical trial, only your initials, gender and a trial number will be used. Your submitting this information constitutes your express acknowledgment and agreement to the above terms.

IMPORTANT: By clicking the submit button below you give consent to Covance to process your application.

I also confirm that I am 18 years of age or older







Telephone

Call our recruiting line for more information about our studies and how you can participate.  We are available Monday - Friday from 9:00am - 8:00pm.
Leeds:0800 591 570

 

Mailing Address

Volunteer Recruitment Team

Covance Clinical Research Unit

Springfield House

Hyde Street

Leeds

LS2 9LH

 

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