Register For Project SAFE

Two simple steps to register

• 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* Female Male Gender*

Day of Birth* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day of Birth*

Month of Birth* January February March April May June July August September October November December Month of Birth*

Year of Birth* 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 Year of Birth*

Do you have any sexual experience?* Yes No Do you have any sexual experience?*

Have you ever had any cervical screening in the last 3 years?* Yes No Have you ever had any cervical screening in the last 3 years?*

Are you undergoing treatment for CIN or cervical cancer?* Yes No Are you undergoing treatment for CIN or cervical cancer?*

Have you ever received HPV vaccine?* Yes No Have you ever received HPV vaccine?*

Are you pregnant?* Yes No Are you pregnant?*

Did you have a hysterectomy?* Yes No 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 here with 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. *

Next

* Required field

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

SMS

Email

Contact Details

Phone number*

Email Address*

Region Hong Kong Island Kowloon New Territories Region*

District Central and Western Eastern Southern Wan Chai Sham Shui Po Kowloon City Kwun Tong Wong Tai Sin Yau Tsim Mong Islands Kwai Tsing North Sai Kung Sha Tin Tai Po Tsuen Wan Tuen Mun Yuen Long District*

Address*

Let us know more about you*

How have you heard about this study? Karen Leung Foundation Website PHASE Scientific Social Media (eg. Facebook, Instagram, etc) School News Health Talk by Karen Leung Foundation How have you heard about this study?

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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 or Sms for successful registration

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