Clinical Trial Enquiry Form

Patient Intake Form

First Name

Last Name

Phone no.

Date of Birth

Sex assigned at birth

Suburb / City of Residence

Condition of Interest

Other Condition

Do you/the patient have a formal diagnosis of a skin condition?

Name of diagnosing doctor/dermatologist

How long have you/the patient had this condition?

How would you describe the severity of your/the patient’s skin condition?

Which areas of the body are affected?

What treatment(s) are you/the patient currently using for this skin condition?

What treatment(s) have you/the patient previously used for this skin condition?

Do you/the patient have any other significant medical conditions?

Are you/the patient currently participating in another clinical trial?

Would you/the patient be willing to attend study visits at our Kogarah clinic?

How did you hear about us?

Is there anything else you would like our clinical trials team to know about your/the patient’s condition?

Privacy Notice

Premier Specialists Pty Ltd, trading as Dermatology Trials Australia, collects the information provided in this form to respond to your enquiry and discuss possible research opportunities. This may include contact and health information about you or, if you are enquiring on behalf of a child or adolescent, the person in your care. Your information will be securely stored, accessed only by authorised members of our clinical research and administration team, and handled in accordance with our Privacy Policy. Submitting this form does not confirm eligibility for, or enrolment in, a clinical trial. If you are enquiring on behalf of someone under 18, you confirm that you are their parent, legal guardian, or otherwise authorised to make the enquiry. For privacy enquiries or requests to access or correct your information, please contact premierdermatologytrials@gmail.com.

I have read the Privacy Notice and consent to Premier Specialists Pty Ltd, trading as Dermatology Trials Australia, collecting, storing and using the information I provide for the purposes described above.

Clinical Trial Enquiry Form

Advancing Dermatology Together