Join a Study

Future Diabetes Treatment Begins
with You

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
Last Name *
First Name *
Street
City
Postal Code
Telephone (home)
Telephone (mobile)
E-mail *
Where did you hear about us
Personal Information
Date of Birth
Gender
Height
Weight
Would you like to participate in medical studies?
No. Please delete my medical data from your database.
Yes. I would like to participate in a study.
I am still 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 am not a diabetic
I am a diabetic and...
I have
Details on Diabetes
Diabetes diagnosed since
Therapy with   Diet
  Insulin
  Tablets
Blood sugar value, after fasting
Date of measured value
Last HbA1c
Date of last measurement
Insulin therapy since
Insulin therapy with
(name of medication)
Other insulins used
(name of medication)
Glucose-lowering tablets
(name of medication)
I suffer from the following diabetes mellitus-related illnesses and side-effects
Medication taken on a daily basis
(including contraceptives)
Allergies