Contact Form


Would you like to actively participate in studies carried out at Profil Institute for Clinical Research in Chula Vista?
Then apply to us directly by completing this form. This same form can, of course, also be used for deregistration purposes. Your medical data will then be deleted immediately from our database. If you do not wish to transfer your data via the Internet, a PDF version of the form is also provided.
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Contact Information:

 

* Last Name:

* First Name:

Street:

City:

Postal Code:

Telephone (home):

Telephone (work):

Telephone (mobile):

* E-mail:

Where did you hear about us:

 

Personal Information

 

Date of Birth:

Gender:

Height:

Weight:

 

Would you like to participate in medical studies?

 

 

I am still interested in taking part in a study and my details are as follows:

 

       How many cigarettes or cigars do you smoke a day.

 

 

        I have

 

Details on diabetes:

 

Diabetes diagnosed since:

Therapy with:


Blood sugar value, after fasting:

Date of measured value:

Last HbA1c:

Date of last measurement:

Insulin therapy since:

Insulin therapy with:
(name of medication)

Other insulins used:
(name of medication)

Glucose-lowering tablets:
(name of medication)

I suffer from the following diabetes mellitus-related illnesses and side-effects:

Medication taken on a daily basis:
(including contraceptives)

Allergies:
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