Understanding MASH - Velocity Clinical Research

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Contact information

Name(Required)

Salutation Given name Surname

Phone(Required)

Email(Required)

Address(Required)

Street and house address City Postal code

Location and study of interest(Required)

CityStudy

For users in Germany and Poland
To find new studies available in your region, please visit one of the following websites:

Personal information

Date of Birth(Required)

Day

Month

Year

Approximate age can help us determine study eligibility (you must be age 18 or older to submit this form).

Do you smoke?

Height (in cm)(Required)

Weight (in kg)(Required)

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Race

Select one or more designations that best describe you. This information can help Velocity better ensure all populations are represented in research.

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White or Caucasian

Data use and declaration of consent

Data protection: The protection of your personal data and privacy is particularly important to us. Please note our privacy notice for patient database. By submitting this form, I agree to the use of my data in accordance with the privacy notice for patient database, in particular regarding smoking status, height, and weight.

Personal information: In order to check whether you are generally suitable for taking part in this study, the preceding voluntary information will help us. By submitting this form, I hereby confirm that the data I have entered may be used to check whether I am fundamentally suitable to take part in this study.

Declaration of consent: After receiving your data, we will contact you by telephone or email to check and discuss your suitability for participation in this study. By submitting this form, I hereby give my revocable consent to the inclusion of my personal data in the patient database. I further agree that Velocity Clinical Research's legal entities may contact me by telephone or email to determine my suitability to participate in this to check the study and discuss it with me. In the event that I am considered as a patient, my data will be stored and processed by Velocity Clinical Research and/or its legal entities (view Velocity's legal entities).

We will inform you about new studies

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Are you Hispanic or Latino?