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Protect Your Pearls Registration

Two simple steps to register - STEP 1

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*

Please selectFemaleMale

Day of Birth*

Please select12345678910111213141516171819202122232425262728293031

Month of Birth*

Please selectJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Year of Birth*

Please select20082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926

Do you have any sexual experience?*

Please selectYesNo

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

Please selectYesNo

Are you undergoing treatment for CIN or cervical cancer?*

Please selectYesNo

Have you ever received HVP vaccine?*

Please selectYesNo

Are you pregnant?*

Please selectYesNo

Did you have a hysterectomy?*

Please selectYesNo

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 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 and Conditions

Please read our Terms and Conditions.

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Sorry, based on your answers you do not meet the project requirement

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Protect Your Pearls Registration

Two simple steps to register - STEP 2

* Required field

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

SMS

Email

Contact Details

Phone Number*

Only valid HK phone numbers are accepted

Email Address*

Website URL*

Region*

Please selectHong Kong IslandKowloonNew Territories

District*

Please selectCentral and WesternEasternSouthernWan ChaiKowloon CityKwun TongSham Shui PoWong Tai Sin Yau Tsim MongKwai TsingNorthSai KungSha TinTai PoTsuen WanTuen MunYuen Long Islands

Address*

Let us know more about you*

How have you heard about this study?

Please selectKaren Leung Foundation WebsiteSocial Media (eg Facebook, Instagram, etc)Others

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