Hypothyroidism

Have you been diagnosed with hypothyroidism? *

Yes

No

Are you currently on a stable dose of Levothyroxine/Synthroid (75cgm - 200mcg daily)? *

Yes

No

First Name *

Last Name *

DOB (month/day/year) *

Email Address *

Phone Number (inc. area code) *

Address (Town/City) *

Zip Code *

Select your nearest clinic *

How did you hear about this trial? *

Are you currently in another study? *

Yes

No

What is your preferred mode of contact? (Check all that apply) *

Phone Call

Text Message

Email

Any

What is the best day(s) of the week to contact you? (Check all that apply) *

Monday

Tuesday

Wednesday

Thursday

Friday

Any

What is the best time of day to contact you? (Check all that apply) *

8am - 10am

10am - 12pm

12pm - 2pm

3pm - 5pm

Any

List any additional areas of research you may be interested in participating in outside of this trial.

When you register your interest with Accellacare, our clinical research specialists will review your information at no cost and connect you with studies you may be eligible for. When we find a match, Accellacare may contact you for further pre-screening or we may share your information with a local site office for them to contact you directly. Your data will be processed as outlined in the Accellacare privacy policy

Data Protection

As the data controller for accellacare.us, Accellacare is committed to protecting the information that you provide. Where you give us your consent, we may use your information to: (a) identify appropriate clinical trials for you and to let you know about them; and/or (b) send you invitations to participate in future study opportunities. You can withdraw your consent at any time, but we may continue some limited processing where we have other legal grounds for doing so.

I consent that Accellacare, its affiliates, partners and the medical professionals who work on clinical research studies with Accellacare may consider my suitability for clinical research studies and contact me about these based on the information I have provided. I understand that my data will be treated as described on this website and that I can find additional information in Accellacare’s privacy policy. *

I Agree

I consent to Accellacare retaining and using my contact details to inform me of clinical study opportunities in the future. I understand I can withdraw my consent/opt-out of this at any time. I understand that my data will be treated as described on this website and that I can find additional information in Accellacare’s privacy policy. *

I Agree

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Hypothyroidism Research Study

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Data Protection

Hypothyroidism Research Study

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Data Protection

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