Register

Please complete this registration form if you would like to be added to our participant database and wish to be contacted during the year to participate in a Zenith study.

Please note that all our studies are run in Dunedin so in order to participate in our studies you must be living in Dunedin or able to spend time in Dunedin during the study period.

Please only complete this registration form once a year.

Note: By completing this registration form you will be added to our database. You will not be automatically registered for the upcoming study. Please contact Zenith if you wish to register for a particular study.

Relevant History
Are you a regular smoker?

Have you smoked during the last 6 months?

Medical History
Do you use an inhaler regularly for asthma?

Do you have a history of Depression?

Do you have a history of migraines?

Do you suffer from any allergies? If so, please specify:
List any other known medical conditions.

List any medications that you take regularly (including herbal remedies supplements and contraceptive therapy)

Personal Details
Given Name
Family Name
Date of Birth
Gender:
Ethnic Origin:

Contact Details
Address
City
Home Phone
Cell Phone
Email Address

Zenith's first point of contact regarding upcoming studies is via email. Are you happy for us to email you?

Additional Information

Have you ever participated in a clinical trial before?

If Yes: year of trial

Where was your trial? Zenith Other:

How did you hear about us?

The Critic Student Job Search Poster Advertising Friend Other:

Consent

I consent to Zenith holding the above information on a database and understand this information will remain confidential and only be used by Zenith

Consent given

Thank you for taking the time to complete this registration form. We will review your application and contact you in the future with upcoming studies.