Registration Form

Please note that most of our studies involving healthy volunteers are run in Dunedin so you must be able to spend time in Dunedin during the study period.

Please only complete this registration form once a year.

Note: By completing this registration form you will be added to our database. You will not be automatically registered for the upcoming study but you will be notified by email when we are recruiting. Please contact Zenith if you wish to register for a particular study.

Relevant History

Are you a regular smoker?

Have you smoked during the last 6 months?

Medical History

Do you use an inhaler regularly for asthma?

Do you have a history of Depression?

Do you have a history of migraines?

Do you suffer from any allergies? If so, please specify.

List any other known medical conditions.

List any medications that you take regularly (including herbal remedies supplements and contraceptive therapy).

Personal Details

Given Name

Family Name

Date of Birth (MM/DD/YYYY)



Ethnic Origin

Contact Details



Telephone Number

Email Address

Additional Information

Have you ever participated in a clinical trial before?

If Yes, what year was the trial?

If Yes, where was the trial?  Zenith  Other

If Other, please state where:

How did you hear about us?  The Critic  Poster Advertising  Friend  Other

If Other, please state how:


I consent to Zenith holding the above information in a database and understand this information will remain confidential and only be used by Zenith.

Consent given