Be A Participant
Auxergo Participant Form
Email address *
Title *
Your answer
First Name *
Your answer
Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Your answer
Parent/Guardian/Carer Name
Your answer
Phone Number *
Your answer
Address *
Your answer
Occupation *
Your answer
Job Role *
Your answer
Current Specialty - If you are a healthcare professional, nurse, or carer, please give your current specialty; if you are not, please write None. *
Your answer
Expertise - If you are a healthcare professional, nurse, or carer, please list all your areas of expertise; if you are not, please write None. *
Your answer
If you answered above, please give the full name of healthcare organisation you work at. *
Your answer
Do you have any allergies? If so, please list them. *
Your answer
Do you have any physicial disabilities? If so, please list them. *
Your answer
Do you have any mental disabilities? If so, please list them. *
Your answer
Do you have any vision issue(s)? If so, please list them. *
Your answer
Do you have any hearing problem(s)? If so, please list them. *
Your answer
Do you have any other medical condition(s)? If so, please list all medical conditions with which you have been diagnosed. *
Your answer
Medication - Please provide the names and strength of any medication you are currently taking, if any. *
Your answer
Do you currently self-inject medication to treat your health condition(s)? *
Required
Are you right-handed or left-handed? *
Required
Do you smoke cigarettes? *
How did you hear about Auxergo? *
Your answer
Auxergo complies with the EU General Data Protection Regulation 2018 (GDPR) and the UK Data Protection Act 2018 (DPA2018) in ensuring the confidentiality of data and ensures that all personal data about participants will be stored securely. *
Yes
No
Consent
Consent to retain the details for future studies
The information is correct to the best of my knowledge
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