Apply now to become a patient

Thank you for applying to become a patient at Synexus. It is important that we have an accurate record of your medical history and we would appreciate you spending a few minutes to click on the boxes below, if you suffer from or have suffered from any of the conditions listed. We will then attempt to match studies that may be of interest to you and only contact you when necessary. If you have any questions or queries please do not hesitate to contact any of our centres or email us on:

Please note all fields marked with * are mandatory.

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The following sections detail various medical conditions. Please tick any of the conditions that you suffer from.

Cardiovascular
Gastrointestinal
Respiratory Disease
Skin
Musculoskeletal
Arthritis:





Musculoskeletal (Continued)
Fracture (A broken bone)


Central Nervous system
Metabolism
Type II Diabetes
Height and weight

To enter your height and weight in meters and kilograms then select ‘Metric’. If your height is 1.2m and weight is 67.5kg, for height enter 1 in first height box and 2 in second height box. For weight enter 67 in first weight box and 5 in second weight box.

To enter your height and weight in stones and height in feet select Imperial. If your height is 5ft 8inches and weight 10 stones 6 lbs, for height enter 5 in the first height box and 8 in the second height box. For weight enter 10 in first weight box and 6 in second weight box.

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Immunological

Psychiatry
Cancer






Genitourinary
Females
Genitourinary (Continued)
Males
Lifestyle




 


 
Sexual disorder (optional)
Males only
Females only