Healthcare Professional Registration

Title * First Name * Last Name * Gender * Date of Birth * GMC/NMC Reference Number Specialty *

Please enter your specialty if not listed above

Sub-Specialty Special Interest Grade Hospital Practice Trust Region

Hospital or Practice Address

Address Line 1 * Address Line 2 Address Line 3 Address Line 4 Town/city * County * Postcode * Country *

Home Address

Address Line 1 Address Line 2 Address Line 3 Address Line 4 Town/city County Postcode Country

Contact Information

Your Email Address * Telephone Number Mobile Telephone Number *

Our interviews are carried out in accordance with current market research codes of conduct and Data Protection Laws. In line with this we require your specific permission before you can participate in marketing research studies. Furthermore, by submitting this registration you agree that the information that you have provided is true to the best of your knowledge and belief. Further information about what we do and how we use your information can be found by reading our Research Participant Privacy Notice.

Please review the statements below, checking your response:

I consent to having my contact information retained for the purpose of participating in research studies.

Yes

I understand that all personal information will remain confidential and that all efforts will be made to ensure that my data is held securely in accordance with our data security policy.

Yes

I understand that my registration and participation is voluntary, and that I am free to withdraw at any time without giving a reason.

Yes

I consent to having my personal information shared with third parties for the purpose of incentive fulfilment.

Yes

We are sorry, but without your consent we are unable to hold your data or include you in future research projects. If you have any questions, please do contact Medicys Limited: Database and Compliance Team, Telephone 01795 42 66 55, privacy@medicysltd.co.uk.