Pandemic Flu Clinical Trial Application - Panthera Clinical Trials

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Date of Birth *

Address *

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Nearest Panthera Clinic *

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Do you consent to the collection and processing of your personal data in accordance with the GDPR for the purposes stated in our privacy policy?

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* To proceed with your pre-screening, we need your consent to collect and process your personal data in accordance with the GDPR. Without this consent, we cannot save your initial data or determine your eligibility, which would result in an incomplete application. Please select 'Yes' to consent. For more information or assistance, contact our team.

Are you 18 years of age or older? *

Are you generally in good health, or is any medical condition you have currently stable? *

Are you pregnant, planning to become pregnant in the near future, or breastfeeding? *

Have you ever had myocarditis or pericarditis? *

Have you been diagnosed with any form of cancer in the past 2 years, other than skin cancer? *

Have you been diagnosed with a condition called Guillain-Barré Syndrome? *

Have you taken chemotherapy or immune suppressing medications in the last 6 months, including methotrexate, infliximab, or regular oral steroids? *

Have you had any steroid injections in joints or the spine in the last 28 days? *

Have you used Tamiflu or other flu antivirals in the past 28 days? *

Flu vaccine in the last 60 days
COVID-19 vaccine in the last 28 days
Any other vaccine (for example travel or routine vaccines) in the last 28 days

Have you received any of the following vaccines recently? (Flu vaccine in the last 60 days, COVID-19 vaccine in the last 28 days, or any other vaccine such as travel or routine vaccines in the last 28 days) *

Have you donated blood in the last 28 days? *

Are you currently, or have you very recently been, taking part in any other clinical trials? *