Patient Trial Enquiry Form

To make an enquiry or register your interest in a current trial, please complete the form below. Or alternatively, send an email to the PACT Team at enquiries@pactnetwork.com.au.

Your contact details will be retained by PACT and may be passed on to a local clinical trial coordinator.

"*" indicates required fields

Name*

First Last

Email*

Enter Email Confirm Email

Phone

Address*

State Post Code Country

What is your age?*

What is your specific diagnosis?*

Other (please specify)

Are you currently taking either Nintedanib (Ofev) or Pirfenidone (Esbriet)?*

Which clinical trial/s are you interested in?*

Do you have a preferred trial centre?*

Other comments

This field is for validation purposes and should be left unchanged.