Panel registration - Exafield UK

Hello & welcome to Exafield's patient panel!
 
Thank you for taking the time to fill out this short questionnaire, we really appreciate it!
 
The purpose of this questionnaire is so that we can add you to our growing panel of particpants.
 
All our studies are confidential and you will be reimbursed. An example of our typical reimbursements are as follows:
  • 10 mins of your time = £10
  • 30 mins of your time = £30
  • 60 mins of your time = £60
Please be as accurate as possible when entering your info and please think carefully about your "confirmed" diagnoses.
 
Once we have your details, we will contact you and inform you of all the study requirements.
 
Thank you for your time and hope to speak to you soon!
The team @ Exafield
 
We will only hold your personal information on our drive. Your details are safe and will never be given to any person(s) or company. This is strictly to allow us to approach you for our future studies/surveys, with respect of your confirmed condition(s). Your details will never be used anywhere else and we abide by data protection laws and BHBIA guidelines. Data protection Act 1998 & BHBIABy completing this questionnaire you agree to be contacted by Exafield ltd for market research studies ONLY. 
If you have any questions, please contact us via the Facebook page

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* 1. Forename:

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* 2. Surname:

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* 3. Title:

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* 4. What is your age?

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* 5. Job Title/Employment status

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* 6. What conditions do you have a confirmed diagnosis for?
Please note: You maybe required to show picture evidence, or feel comfortable with us getting in touch with your doctor.

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* 7. Are you happy for us to contact you via the info you have provided about future studies?

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* 8. UK Region

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* 9. Postcode:

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* 10. What is the best phone number to contact you on?

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* 11. What is the best email to contact you on?

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