Alcohol Consumption Clinical Trial Application

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Name *

Email *

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Phone *

Best time to call? *

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

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 between 18 and 75? *

Is your body mass index (BMI) at least 22 kg/m²? *

(Male only) Do you typically consume 35 units or more of alcohol per week?

(Female only) Do you typically consume 18 units or more of alcohol per week?

Do you typically consume these units or more of alcohol per week? *

Are you seeking treatment for your drinking and motivated to reduce your alcohol intake? *

Are you currently pregnant or planning to become pregnant during the trial period? *

or alcohol poisoning

Do you have type 1 diabetes or take regular insulin? *

Have you been admitted to hospital for alcohol poisoning within the past 6 months? *

Have you been prescribed any medication in the community to treat or prevent alcohol withdrawal within the past 6 months? *

Do you have any surgery planned in the next 18 months? *

Basal cell skin cancer is allowed.
Squamous cell skin cancer is allowed if fully removed and with no recurrence for at least 3 years.

Have you had a cancer diagnosis in the past 5 years? *

Are you currently using any weight-loss injections or other weight-loss medication? *

Do you have a history of pancreatitis? *

Are you currently participating in another clinical trial where you receive regular medication? *