Home  Update Profile
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Update Investigator Details
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Please use this form if you are a qualified Physician who wishes to be considered for participation in AstraZeneca Clinical Trials. Please note that registration does not guarantee participation. If you would like to contact AstraZeneca for any other reason, please use our contact us form.
Please use the Tab key or mouse to select each field.
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Please review the details you have entered. If they are correct then press the submit button
at the bottom of the page to send us your details.
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Title
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If Other, please specify:
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First name
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Middle name
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Last name
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Primary Location
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Primary hospital, institute and/or department
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Address
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Address Line 2
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City
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Zip/Postal code
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Country of Residence
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State (US only)
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Current Email address
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Enter new Email address
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Phone
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Alternate Phone
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Fax
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Additional Institution Affiliation
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Clinical speciality
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If Other, please specify:
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Sub speciality:
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If Other, please specify:
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Second Clinical speciality
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If Other, please specify:
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Sub speciality:
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If Other, please specify:
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Research interest
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If Other, please specify:
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Type of medical facility
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If Other, please specify:
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Patient Population Demographics (Check all that apply)
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Patient Population Demographics (Check all that apply)
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Pediatric
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Adult
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Elderly
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Experience of clinical studies
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Number of clinical studies (within last five years)
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Phases of drug development
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How did you find out about this web site?
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If other, please specify:
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Professional society, specify:
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hide2
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I have read and understood the contents of this form and the following Consent Notice.
By ticking the box you consent to AstraZeneca UK Ltd processing personal information about you (some of which may be sensitive) for the purposes of:
a) assessing whether to enter into further agreements with you and/or the organization you represent;
b) building a contacts database of health care professionals; and
c) complying with any applicable legal and/or regulatory requirements; together known as the 'Uses.' AstraZeneca may share your personal information with its group companies and/or regulatory authorities and/or third party partners or suppliers (who may be located anywhere in the world). AstraZeneca's third party partners' and suppliers' activities will be restricted, under written contract, to the Uses. Nothing in this collection notice affects any other permissions you may have granted, or rights AstraZeneca (or its group companies) may have, in relation your personal information which it processes about you now or in the future.
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I certify that I am qualified to practice medicine in my country of residence
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I understand that completing this form expresses my interest in working with AstraZeneca and does not guarantee participation in AstraZeneca clinical trials.
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I authorize AstraZeneca to use the above information to contact me by telephone, SMS, fax, or email.
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Your details
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| Title |
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| First name |
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| Middle name |
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| Last name |
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Primary location
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| Name of hospital, institute and/or department |
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| Address |
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| Address Line 2 |
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| City |
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| Zip/Postal code |
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| Current email address |
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| New email address |
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| Country of Residence |
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| State |
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| Phone |
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| Alternate Phone |
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| Fax |
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| Additional Institution Affiliation |
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Your speciality
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| Clinical speciality |
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| Sub speciality: |
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| Second Clinical speciality |
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| Sub speciality: |
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| Please type your research interest |
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| Type of medical facility |
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Patient population demographics
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| Pediatric |
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| Adult |
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| Elderly |
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Experience of clinical studies
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| Number of clinical studies (within last five years) |
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| Phase I |
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| Phase II |
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| Phase III |
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| Phase IV |
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| If more information is needed, would it be acceptable for an AstraZeneca Representative to contact you as a follow up to your registration? |
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I have read and understood the contents of this form and the Consent to Process Personal Data Policy.
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I certify that I am qualified to practice medicine in my country of residence
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I understand that completing this form expresses my interest in working with AstraZeneca and does not guarantee participation in AstraZeneca clinical trials.
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I authorize AstraZeneca to use the above information to contact me regarding AstraZeneca Clinical Trials.
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