enquiry form

Request information about volunteering at HMR Please complete the form below and press 'submit'.
We will contact you with a list of studies that may be suitable. Fields marked with a ' * ' are required.

First name*
Middle name(s)
Surname*
Contact phone No.*
Email address*
Date of birth*	--- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 --- January February March April May June July August September October November December --- 2010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920191919181917191619151914191319121911
Nationality
Ethnic origin
Your sex*	Male   Female
Your Height	--- Cm Feet/Inches
Your Weight	--- Kilograms Pounds
Smoker*	Yes   No
Obese*	Yes   No   Unsure
Asthmatic*	Yes   No   Unsure
If you answered female above:
Contraceptive pill	Yes   No
Hysterectomy	Yes   No
The information that you submit will be held by us (Hammersmith Medicines Research Unit Ltd) for the sole purpose of allowing us to contact you to let you know about studies that you might be able to participate in. We may keep the information about you on paper and in a computer database. If you do take part in a study, some of the information about you may be seen by the organisers of the study, and by the authorities that regulate medicines in the UK and other countries. However, your name would not appear on any of the study documents that we might prepare: we would use only your initials, sex, date of birth and a trial number. By submitting this information, you confirm that you understand and agree with our proposed use of your information. So, you should click the 'submit' button, below, only if you consent to our processing your information as described above.

Register now! Senior Trials - Register now! Obesity Trials - Register now! Asthma Trials - Register now!

• Fill out the enquiry form to submit your details.
• Call Freephone : 0800 783 8792
• e-mail :

If you have a friend who may be interested in doing their first trial at HMR, please give us their name and telephone number. If they successfully finish a trial with us, we’ll give you £100!