United States

Thank you for your interest in participating in a clinical research study with Covance. You can submit your information using the Contact Us form or call our Recruitment Center at the numbers listed below. We look forward to talking to you and thank you for your interest!

INFORMATION

Note: Bold fields are required

Select Site:

AllAustin, TexasDallas, TexasDaytona Beach, FloridaEvansville, IndianaHonolulu, HawaiiMadison, Wisconsin

Study No:

First Name:

Middle Name:

Last Name:

Address Line 1:

Address Line 2:

City, State, Zip Code:

County:

Telephone Number:

 HomeMobileWork

Telephone Number:

 HomeMobileWork

Email Address:

Date of Birth:

- JanFebMarAprMayJunJulAugSepOctNovDec -
dd,mmm,yyyy i.e., 01, Oct, 2009

Ethnicity:

AfricanAfrican AmericanAsian (non-Japanese)CaucasianChineseFilipinoHispanic/Latin AmericanJapanese 1st GenerationJapanese 2nd GenerationJapanese 3rd GenerationJapanese 4th+ GenerationKoreanMixedNative AmericanOtherPacific Islander

Gender:

MaleFemale

Height:

Feet  Inches

Weight:

 Pounds

BMI Calculation:

Do you smoke:

YesNo

If yes, how many cigarettes per day?

Ladies Only:

Are you surgically sterile ?

YesNo

Are you post-menopausal?

YesNo

Do you use contraception?

YesNo

How did you hear about us?

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

Please add me to the database, but I am not interested in a particular study at this time.

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

Security Code:

Enter Code:

The information which you submit will be held by 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 the United States. 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! All times listed are for the Central time zone.

• Austin - (877) 851-1064
  • Monday - Friday:  8:00 am - 7:00 pm
  • Friday:   8:00 am - 7:00 pm
  • Saturday:  Closed
  • Sunday:  10:00 am - 6:00 pm
• Dallas - (866) 429-3700   Se Hablo Espanol
  • Monday - Friday:  8:00 am - 7:00 pm
  • Saturday:  Closed
  • Sunday:  10:00 am - 6:00 pm
• Daytona Beach - (386) 257-1433
  • Monday - Thursday:  7:00 am - 8:00 pm
  • Friday:   7:00 am - 7:00 pm
  • Saturday:  Closed
  • Sunday:  11:00 am - 7:00 pm
• Evansville - (866) 913-4434
  • Monday- Thursday:  7:00 am - 8:00 pm
  • Friday:   7:00 am - 7:00 pm
  • Saturday:  Closed
  • Sunday:  10:00 am - 6:00 pm
• Honolulu - (808) 441-6327  or for Japanese speaking callers:  (808) 441-6361
  • Monday- Friday:  7:30 am - 5:00 pm
• Madison - (800) 732-2528
  • Monday- Thursday:  7:00 am - 8:00 pm
  • Friday:   7:00 am -7:00 pm
  • Saturday:  Closed
  • Sunday:  10:00 am - 6:00 pm