Enroll in a Study

Ver en EspañolIf you would like to participate in a clinical study at Profil Institute for Clinical Research, please apply to us directly by completing this form. This same form can be used for deregistration purposes, in which case your medical data will then be deleted immediately from our database. If you do not wish to transfer your data via the Internet, a PDF version of the form is also provided.

  • Contact Information

  • Personal Information

  • Would you like to participate in a clinical study?

  •   No. Please delete my medical data from your database.
      Yes. I would like to participate in a study.
  • I am interested in taking part in a study and my details are as follows

  •   Nonsmoker
      Smoker
  • How many cigarettes or cigars do you smoke a day?

  •   For the last six months or longer
      For less than six months
  •   I do not have diabetes
      I do have diabetes
  • Details on Diabetes

  •   Diet
      Insulin
      Tablets