Chlamydia or Gonorrhea Infection

First Name *

Last Name *

DOB (month/day/year) *

Email Address *

Address (Town/City) *

Zip Code *

Phone Number (inc. area code)* *

**By registering and providing your telephone number, you agree to receive text messages from Accellacare for the purposes above at the number you provide. Message and data rates may apply. Message frequency will vary. No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. For help, reply HELP to any message. To opt-out, reply STOP to any message.

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

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

Monday

Tuesday

Wednesday

Thursday

Friday

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

8am - 10am

10am - 12pm

12pm - 2pm

3pm - 5pm

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

When you register your interest with Accellacare (which is part of ICON plc), our team will add your information to our database, review your information and connect you with studies that you may be eligible for. When we find a match, Accellacare clinical research specialists will contact you directly for further pre-screening by phone and may refer you on to Accellacare sites or collaborating third-party sites for further on-site pre-screening. We may also contact you in the future by phone call, text message, or email regarding future trials you may be interested in based on the information you provide to us. The clinic you choose in the registration form below may be a third-party study site (which will be clearly indicated) that collaborates with Accellacare on clinical trials. If you select a third-party site, you agree that we may share your personal data with that clinic for further pre-screening. That clinic will be independently responsible for processing your personal data in accordance with all applicable data protection laws.

Data Protection

ICON plc is responsible for the personal data, including data related to your health, race, and ethnicity you choose to provide. We rely on your consent to add your information to our database, use this information to identify potentially appropriate clinical studies for you and contact you about them. When we call you for further pre-screening, note that these calls will be recorded. If you have selected a third-party site, we will share your information with this site so they can contact you for further pre-screening.

You can withdraw your consent at any time, for example by following instructions to do so in emails or text messages you receive from us, or by telling our patient recruitment team when speaking with them. This does not affect the lawfulness of the processing prior to your withdrawal. Additional information on how your data will be processed and how you can exercise your rights, can be found in our Privacy Policy. Please confirm if you consent to ICON plc collecting, using and sharing your personal data for the above purposes. *

I Agree

Please enter the security code:

Chlamydia or Gonorrhea Infection Research Study

Submit to learn more:

Data Protection