Clinical Trial Patient Onboarding Eligibility Form 
Please answer each question with as much information as possible, a staff member will contact you to discuss your eligibility
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First Name *
Last Name
Contact Number *
Email  *
Age 
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Suburb of Residence
Which dermatological condition are you interested in treating through a clinical trial?
(Please select one option)   *
Has your dermatological condition been formally diagnosed by a Medical Practitioner?
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If your answer was yes to the previous question, please indicate the name of the Medical Practitioner who made the diagnosis
What year were you diagnosed with this condition (if applicable)
How would you rate your condition severity? 
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Please outline any current treatment/therapy you are undergoing for this condition
Please outline any previous treatment/therapy you have undergone for this condition
Do you have any other dermatological conditions aside from the condition listed above?
Have you been diagnosed or have undergone treatment for cancer in the last 5 years?
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Where did you hear about our clinical trial centre?
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Please write your full name to confirm you consent to a staff member of Premier Specialists Pty Ltd contacting you via phone and/or email to discuss your eligibility and information provided in this form *
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