Adnexi - Participant Information Request

As explained in our Privacy Policy, 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.

Thank you for submitting your privacy request. We will review your request and respond within 30 days (or within 20 days for requests made under Mexico's Federal Law on Protection of Personal Data). You will receive a confirmation at the email address you provided.

Something went wrong. Please try again or email us directly at [email protected].

Verify Your Identity

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. We will use this to communicate with you about your request.

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? *

I am submitting for myself I am submitting on behalf of someone else

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

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 or letter you received.

How did you submit your information?

Online prescreener form Phone / SMS Email Recruitment partner / referral I'm not sure

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.

Right to Know / Access — I want to know what prescreening information you hold about me and receive a copy. Right to Delete — I want you to delete my prescreening information. Right to Correct — Some of my prescreening information is inaccurate and I would like it corrected. Right to Opt-Out of Sale / Sharing — I want to opt out of the sale or sharing of my personal information. Right to Restrict Processing — I want to restrict how my information is processed. Right to Data Portability — I want my data in a structured, machine-readable format. Right to Limit Use of Sensitive Information — I want to limit how my sensitive personal information (e.g., health data) is used. Withdraw Consent — I wish to withdraw any consent I previously provided for the processing of my prescreening data.

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.

Acknowledgments

Please review and check each box.

I confirm that the information I have provided is accurate and that I am the individual (or authorized representative of the individual) whose data is the subject of this request. I understand that Adnexi may need to coordinate with or redirect my request to the study Sponsor or participating research site, as Adnexi acts as a service provider/processor on their behalf. I have read the Privacy Policy and understand how my data is collected and processed.

Manage Your Personal Information