Research for the Future Registration Form

Thank you for your interest in research.

Taking part in research means you are helping the NHS discover better ways to prevent, diagnose and manage a range of health conditions including long COVID, diabetes, heart, lung and kidney diseases.

Anyone over the age of 18 can register with Research for the Future to hear about opportunities to take part. Read more about our work .

If you have any difficulty completing this form please contact us.

Fields marked with * are mandatory

Title *

First name *

Middle name(s)

Last name *

Date of birth * Date of birth (day) Date of birth (month) Date of birth (year)

Gender *

Gender

Male

Female

Other

Ethnicity *

Please specify other*

Address 1 *

Address 2

Address 3

Town / city *

Postcode *

The postcode entered is not recognised, please try again
If you are having problems registering your postcode please contact us or telephone 0161 206 3636

Telephone * (preferred)

Telephone (alternative)

Best time to call

Communication needs*

Communication needs

None

Visual

Hearing

Speech impairment

Communication support required*

Communication support required

None

Large print

Yellow paper

Email

Telephone

Email

Confirm email

Your health

NHS number

This can be found on your prescription or a letter from the NHS

Have you ever tested positive for Covid-19? *

Examples of a test are: PCR swab, or lateral flow

Have you ever tested positive for Covid-19?

Yes

No

Not sure

Was your test more that 12 weeks ago? *

Was your test more that 12 weeks ago?

Yes

No

Have you fully recovered? *

Have you fully recovered?

Yes

No

Have you received at least one dose of a vaccine for Covid-19? *

Have you received at least one dose of a vaccine for Covid-19?

Yes

No

I have*

I have

Diabetes

Respiratory disease

Heart disease

Kidney disease

None of these conditions

Please complete the diabetes section below

Type of diabetes *

Please specify other*

Year of diagnosis *

How did you hear about us? *

Please specify other*

I confirm*

I confirm

I want to be contacted about ANY health research

I only want to be contacted about health research relating to the health condition(s) I have told you about

Please complete the following fields above:

The following fields above have errors:

If you have any problems completing this form please contact us or telephone 0161 206 3636.

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