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Careers at ICON

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Register for clinical trial Neurological disorders

With this form you register yourself for this trial. Your registration is completely without obligation. ICON handles the personal data of visitors to our website and participants with care.

Previously registered at ICON?

Yes
No

Name

First name*

First name*

Preposition

Preposition

Last name*

Last name*

Gender*

Male
Female

Date of birth

Day*

Day*

Month*

Month*

Year*

Year*

Address

Country*

Country*

Enter your address here.

Enter your address here.*

Street name*

Street name*

House No.*

House No.*

Postal code*

Postal code*

City*

City*

Contact details

Telephone number*

Telephone number*

E-mail address*

E-mail address*

I would like to be kept informed about trials via:

Email

Email

SMS

SMS

Yes, I sign up for the general newsletter, which I receive a maximum of 4 times a year

Yes, I sign up for the general newsletter, which I receive a maximum of 4 times a year

Do you smoke?*

No
Yes

How much do you smoke? Select tobacco consumption

How much do you smoke? Select tobacco consumption

Do you have a medical condition?*

No
Yes

What medical condition(s) do you have and medicines do you use?

What medical condition(s) do you have and medicines do you use?

Are you currently under the treatment of a doctor?*

No
Yes

Please state why you are under the treatment of a doctor.

Please state why you are under the treatment of a doctor.

Length and weight

Height (in cm)*

Height (in cm)*

Weight (in kg)*

Weight (in kg)*

BMI

Hebt je een vraag of opmerking?

Geef hier geen aanvullende gevoelige of medische persoonlijke gegevens op.

Geef hier geen aanvullende gevoelige of medische persoonlijke gegevens op.

Registration is not obligatory. Your privacy is our priority. Read in our privacy statement what we do with your personal information

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You will receive a confirmation of your registration at the specified e-mail address.

Name

First name*

First name*

Preposition

Preposition

Last name*

Last name*

Gender*

Male
Female

Date of birth

Day*

Day*

Month*

Month*

Year*

Year*

Contact details

Telephone number*

Telephone number*

E-mail address*

E-mail address*

I have read the privacy statement*

This site is protected by reCAPTCHA and the Google, Privacy Policy and Terms of Service apply.

Reasons to participate:

1.

No new medicines without clinical research

New or better medicines are crucial to all of us, but even more so to patients who rely on medicines.
2.

You receive a nice reward

We offer you a nice compensation for your contribution!
3.

Time to relax, work or study

While you are at the research center you have time for yourself. Make it useful or use the time just to relax!
4.

Have fun together

You can do all sorts of things in the research center: play a game with others or enjoy gaming.

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