covance

test with the best

  

Switzerland



INFORMATION
Note: Bold fields are required

Select Location:

Study No:




First Name:

Middle Name:

Last Name:

Address Line 1:

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Zip Code:

City:

Telephone Number:
 

Telephone Number:
 

Email Address:

Date of Birth:
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Ethnicity:

Gender:
Height:
 cm

Weight:
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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?


How did you hear about us?


Please contact me; I am interested in participating in a particular study .

I am a current or past volunteer, please update my contact information.


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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 history and a separate consent form if you are selected to participate in a study. Information from this medical history 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 Switzerland. Parts of your data may be disclosed to the organizers 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

The Covance Recruitment Call Center is available to provide you with more information about our studies and how you can participate.  We look forward to your call!

 

Basel 0041 - (0) 61 565 15 15

  • Monday- Friday: 9:00 - 12:00 and 14:00 - 16:00

 

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