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Manage Your Personal Information (Potential Clinical Trial Participants)

Manage Your Personal Information (Potential Clinical Trial Participants)

Manage Your Personal Information (Potential Clinical Trial Participants)

This page is for individuals (or their parents/guardians or legally authorized representatives) who applied for, were referred to, or completed a prescreener for a clinical study that Adnexi supports on behalf of a pharmaceutical Sponsor and participating research sites.

As explained in our Privacy Notice, we may collect contact details and prescreening information (including certain health‑related data) to determine preliminary eligibility and coordinate referrals. We process this data as a service provider/processor to the Sponsor and research sites.

Please use this form to exercise your privacy rights regarding prescreening information you submitted to Adnexi. In some cases, we may need to coordinate with or direct your request to the study Sponsor or participating research site. All fields marked with an asterisk (*) are required.

This page is for individuals (or their parents/guardians or legally authorized representatives) who applied for, were referred to, or completed a prescreener for a clinical study that Adnexi supports on behalf of a pharmaceutical Sponsor and participating research sites.

As explained in our Privacy Notice, we may collect contact details and prescreening information (including certain health‑related data) to determine preliminary eligibility and coordinate referrals. We process this data as a service provider/processor to the Sponsor and research sites.

Please use this form to exercise your privacy rights regarding prescreening information you submitted to Adnexi. In some cases, we may need to coordinate with or direct your request to the study Sponsor or participating research site. All fields marked with an asterisk (*) are required.

Verify Your Identity

Verify Your Identity

This information is required to process your request.

This information is required to process your request.

Full Name*

(If submitting on behalf of someone else, enter the participant’s full name.)

Email Address *

(Use the same email you used for the study prescreener, if possible.)

Mobile Number

(Optional; helps us find your record if you provided a phone number during prescreening.)

ZIP/Postal Code *

(The location you entered in the prescreener.)

Date of Birth (Participant)

Optional, but recommended for matching.

Are you submitting this request for yourself or on behalf of
someone else? *

Myself

On behalf of a minor (parent/legal guardian)

On behalf of another adult (legally authorized representative)

If submitting on someone’s behalf, describe your relationship
and authority

(e.g., parent, legal guardian, power of attorney; you may be asked to provide documentation.)

Participant & Study Details

Participant & Study Details

Study Name or Condition (if known)

(e.g., “BERKELEY‑03 – CMS” or “congenital myasthenic syndromes”.)

Sponsor Name (if known)

(The company named on the study materials or letter you received.)

How did you submit your information?

Online form (prescreener)

Phone

SMS/text

Email

Other/Not sure

Select Your Privacy Request(s)

Select Your Privacy Request(s)

Choose one or more rights you wish to exercise. Availability may vary by jurisdiction; we will guide you if an alternative applies.

Choose one or more rights you wish to exercise. Availability may vary by jurisdiction; we will guide you if an alternative applies.

Right to Know/Access – Please send me a copy of the personal information Adnexi holds about me in connection with clinical‑trial prescreening.

Right to Delete – Please delete my prescreening information from Adnexi’s systems, subject to legal/contractual requirements and allowed exceptions.

Right to Correct – The information you have about me is inaccurate; I would like to request a correction.

Right to Limit Use/Disclosure of Sensitive Personal Information (where available) – Limit the use/disclosure of my health‑related information to what is necessary to provide the services I requested and as otherwise permitted by law.

Right to Opt‑Out of Sale or Sharing (where applicable) – I wish to opt‑out of any “sale” or certain types of “sharing” of my personal information under applicable state privacy laws.

Withdraw Consent to Be Contacted About This Study/Similar Studies – Stop contacting me about this or similar studies.

Provide Details (If Applicable)

Provide Details (If Applicable)

Corrections or Additional Information
(If you selected Right to Correct or have other details to help us process your request, enter them here.)

Corrections or Additional Information
(If you selected Right to Correct or have other details to help us process your request, enter them here.)

Acknowledgments

Acknowledgments

Please review and check each box:

Please review and check each box:

I am the participant or I am authorized to act on the participant’s behalf and, if requested, I can provide documentation of that authority.

I understand Adnexi may need to coordinate with or direct my request to the study Sponsor or participating research site and that certain information may be retained as required by law, for security/integrity, or to fulfill recordkeeping obligations.

I consent to be contacted about this privacy request using the contact details I provided.

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Patient-Centric Strategies?

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© 2025 Adnexi All rights reserved.

Terms & Conditions

Ready to Accelerate ⚡
Patient-Centric Strategies?

Fill out the contact form, and our team will reach out to schedule a meeting.

Book a demo

© 2025 Adnexi All rights reserved.

Terms & Conditions

Ready to Accelerate ⚡
Patient-Centric Strategies?

Fill out the contact form, and our team will reach out to schedule a meeting.

Book a demo

© 2025 Adnexi All rights reserved.

Terms & Conditions

Ready to Accelerate ⚡
Patient-Centric Strategies?

Fill out the contact form, and our team will reach out to schedule a meeting.

Book a demo

© 2025 Adnexi All rights reserved.

Terms & Conditions