Charles River Clinical Participant Registration Form

If you are interested in participating in a Charles River Clinical Services study, please fill out the form below. If you do not receive a response the next business day, or if there are any technical difficulties when submitting this form, simply email us stating you are interested in more information.

We will be in touch with you shortly.

The fields marked with an asterisk (*) are required.

*First Name:
*Middle Name:
*Last Name:
Preferred Name:
*Sex:		Male Female
*Date of Birth:
*Address1:
Address2:
*City, State, Zip:
Country:
*Day Phone:
Evening Phone:
E-mail Address:

Study Number That You Are Interested In (If you have more than one, use Comments. This is not a required field.):
NW#: -

* When are you available for overnight stays?
Anytime
Weekends
Weekdays
Outpatient Only
Short Stays Only
Long Stays Only

Child Bearing Status (female only)
Post-Menopausal
Birth Control Pill
Hysterectomy
Tubal Ligation
Oophorectomy (removal of both ovaries)
Barrier method (Condom, diaphram, etc.)
Abstinence
IUD
No contraception
Other (please list):

Child Bearing Status (men only)
Potentially Able to Bear
Biologically Sterile
Fertile
Vasectomy
N/A
Other: Please specify:

* Smoking Status:
None (no nicotine w/in the last 90 days)
1 to 10 Cigarettes/Day
11 to 20 Cigarettes/Day
21 or more Cigarettes/Day
Occasional Smoker/Social Smoker: Please Specify Amount:
Other: Specify:

* Please list any prescription or over-the-counter medication you have taken within the last 30 days (Including birth control, vitamins, herbal supplements). If you have not taken any prescription or over-the-counter drugs in the past 30 days, type None.

* If you are allergic to medications, please list what they are, and the reaction you have to the medication (e.g. Penicillin: rash, Codeine: swelling). You do no not have any alleriges, type None.

* Please list any chronic medical conditions or diagnosis (e.g. asthma, diabetes, high blood pressure, depression, etc.) If you do not have any chronic medical conditions, type None. :

* Please list any special dietary needs (e.g. vegetarian, lactose intolerant, diabetic). If you do not have any special dietary needs, type None:

* If Vegetarian/Vegen/Lactose, would you be willing to eat meat/dairy if the study required it?
Yes No N/A

* Do you have (please check all that apply)?
Hepatitis A
Hepatitis B
Hepatitis C
HIV
None

* Have you used any illicit drugs in the past year?
Yes No

If "yes", please approximate the last date of use and what was used

* Height: * Weight:

* How did you hear about us? Please be specific (who told you: John Smith, which newspaper: Seattle Times, what radio station: KISW 99.9, or the specific TV channel and program: KING 5 Dr. Phil)

* What would you classify your race as?
African American/Black
American Eskimo
Asian
Caucasian
Hispanic
Latino
Middle Eastern
Native American
Pacific Islander
Other:

* Can we retain this information in our confidential database?
Yes No

* Can we leave a message on your voicemail about our upcoming studies?
Yes No Other:

* Would you like us to contact you with information regarding future studies?
Yes No

Comments:

* Security Code:

Please type the security code in the field below: