COVID-19 Therapy Trial

Interested in participating in a study?

In order that TASK may contact you for a possible study in the future, we would like to include personal information about you in our data base. This personal information will help us identify studies that you may be interested to take part in. It may also be used for general information in helping us plan for new studies best suited to you.

Under the Protection of Personal Information Act 2013, TASK is responsible for how your information is collected, stored, used and disclosed (shared). This means it will be stored privately (confidentially) with access control measures and will not be shared with third parties, or transferred to other countries.

TASK will keep your data in the data base for future use. You have the right to access all information collected about you and if applicable ask for corrections. You also have the right, at any time, to withdraw your consent and ask TASK to remove your information from the data base at which point your profile will be deleted from the TASK data base. To do so, or if you have any questions, concerns, or complaints about how your information is handled, please contact your regular TASK contact or contact us via our website

By completing this form, you provide consent for your information to be collected, stored and used as described.

First Name
Last Name
Email Address
Address (unit, street, suburb)
ID number
Male or female
  • - select a option -
  • Male
  • Female
Own transport
  • - select a option -
  • Yes
  • No
Preferred language
  • - select a option -
  • English
  • Afrikaans
  • Other, if selected please specify below
Other Language
Height (cm)
Weight (kg)
Smoker (yes/no)
Do you suffer from any of the following
Anything else? Let us know
Emergency / additional contact: First Name
Emergency / additional contact: Last Name
Emergency / additional contact Phone