High / Bad Cholesterol Clinical Trial Application

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Name *

Email *

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Phone *

Best time to call? *

Date of Birth *

Address *

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City

State / Province / Region

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Country

Nearest Panthera Clinic *

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? *

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 aged 18 or over? *

Have you been diagnosed with high cholesterol? *

Checkboxes

A stroke or mini-stroke (TIA)
A heart attack
A stent fitted or heart bypass surgery
Poor circulation or blocked arteries in your legs
A significant blockage in an artery (neck, leg, or heart)
Type 2 diabetes

Are you currently taking a statin medication for your cholesterol? *

Are you currently taking any of the following medications for cholesterol? (simvastatin, pravastatin, pitavastatin, inclisiran, or gemfibrozil) *

Have you ever taken a medication called bempedoic acid? *

In the past 3 months, have you had a heart attack, stroke, heart surgery, or been hospitalised for chest pain? *

Have you been hospitalised for heart failure in the past 5 years? *

In the past 3 years, have you been treated for cancer requiring surgery, radiation, or chemotherapy? *

taking surgery, heart

Are you currently pregnant, breastfeeding, or planning to become pregnant in the near future? (If applicable) *