Phoenix Pharma PARTICIPANT REGISTRATION FORM

Full Name and Surname: Name: Gender: Male Smoking: Race: Any Allergies: Never

SOP 06-CL FM 06-CL01-01 (Effective date: 10 Apr 2013)

Black

Caucasian
Currently

Female

ID-number: Home language:

Comments: Mixed Race Other:

Ex smoker

Residential Address: Tel no. (W): Cell phone no.: Tel no. (H): E-mail:

Diagnosis (Tick all the appropriate diagnoses below) Healthy (No disease, no medication) Liver Failure Asthma High Cholesterol (or dyslipidaemia) COPD (emphysema) Coronary Artery Disease (Angina/Heart attack) Diabetes: Insulin dependent (Type 1) Diabetes: Adult onset (Type 2) Other (specify): Medication (Dosage not necessary):

Hypertension (high blood pressure) Arthritis Parkinsons Disease Psychiatric Conditions Kidney Failure Gout Other (specify):

I have expressed an interest in possibly taking part in research projects. I understand that it may be necessary to perform some procedures to ascertain my suitability for potential participation in clinical research projects and trials. I hereby consent to the recording of my demographic and medical history, and to a physical examination, lung function test, measurement and recording of my weight, height, blood pressure, pulse and a blood test for eg. blood sugar as appropriate. Results: Any special instructions:

I understand that the results of these examinations will be provided to me, and that it is my responsibility to take further action where necessary. I also agree that information thus gathered may be kept by PHOENIX Pharma for possible future use for research. If I would like to withdraw this information from PHOENIX Pharma records in the future, I will inform the company of this. I understand and hereby consent to PHOENIX Pharma personnel, appropriate personnel representing the Sponsor and Regulatory authorities, reviewing the relevant sections of any of my medical records pertaining to a study, but that all information accessed and obtained will be treated as confidential.

Signature of Patient

Initials and Surname

Date

Signature of Clinical Investigator / Staff Member

Initials and Surname

Date

FM 06-CL01-01 Participant Registration Form Approved by Pharma-Ethics on 03 Apr 2013

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