Register Your Interest Please Complete the Registration Below Please read our CMAX Privacy Policy Name* First Last Email Address Sex*MaleFemaleDate of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Height (cm)*Weight (kg)*Race*Choose your raceAboriginalAfricanAsianCaucasianMiddle EasternOtherOtherAddress*Address line 1Suburb*State*Postal Code*Country*Phone Number*Do you drink alcohol? Yes Quantity of standard drinks / dayAre you a smoker? Yes Quantity per day (cigarettes)Do you have an allergy to any food or medications? Yes If so, please specifyDo you take any medication on a regular basis? Yes If so, please specifyFemales only: Are you either post-menopausal or surgically sterile?YesNoIf 'yes'Post-menopausalSurgically SterileTubal LigationIf 'no', are you currently taking a form of contraception?YesNoIf 'yes'PillImplantInjectionIntrauterine DeviceRegular or most recent Doctor/Medical Centre DetailsDo you suffer from or have a history of any of the following? Hepatitis B, C, or HIV Mental Illness Asthma Epilepsy Diabetes Type 1 Diabetes Type 2 Kidney Disease Liver Problems Osteoarthritis Rheumatoid arthritis Psoriasis Gastrointestinal Disorders High Blood Pressure High Cholesterol Heart Condition Eczema Cancer Other If 'Cancer', pleae specifyIf 'Other', please specify* I agree for my information to be entered in the CMAX database for future contact * I have read and understood CMAX's Privacy Policy * There is no photography of any description allowed in the CMAX unit. I agree not to take any photos at all within the CMAX unit
