Register For Project SAFE

1. Participant Information
2. Contact information

Please fill in the following information if you would like join the project.
All personal details will be kept strictly confidential.
* Required field

First Name (Same with HKID)*

Last Name (Same with HKID)*

Gender*

Day of Birth*

Month of Birth*

Year of Birth*

Do you have any sexual experience?*

Have you ever had any cervical screening in the last 3 years?*

Are you undergoing treatment for CIN or cervical cancer?*

Have you ever received HPV vaccine?*

Are you pregnant?*

Did you have a hysterectomy?*

I understand that this program is part of a clinical study and enrollment is only for participants who agree to the terms and conditions on the clinical study consent form presented at the clinic on the day of appointment.*

I confirm, that I have read and understood the information sheet for the project and have had the opportunity to view and study the educational videos provided for a better overall grasp on how to protect myself against cervical cancer.*

I understand that my participation is voluntary and that I am free to withdraw at any time, without giving any reason, without my medical care or legal rights being affected.*

I agree to take part in the above cervical screening programme.*

I herewith acknowledge that, if I am currently experiencing irregular bleeding, spotting or pain during my menses, sex or randomly, I cannot join the project. We kindly encourage you to contact your GP immediately and seek a professional opinion.*

I have read and agree to the Terms & Conditions.*

* Required field

How would you like to be contacted for the program?*

SMS

Contact Details

Phone number*

Email Address

Region*

District*

Address*

Let us know more about you.*

How have you heard about this study?

Thank you for registering to the project

You are now registered to Project SAFE - our Partner PHASE Scientific will send you a SMS for confirmation in 1-2 working days. Please call Kinetics Integrated Medical and Health Centre within two weeks from your sign-up date to arrange an appointment for the screening.

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Thank you for your registration! We will put you in our first priority list.

The project quota is full. You will be notified by an Email / SMS for successful registration.

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