Registration of Interest - The LOCA Study

Please complete your details below to be contacted by a member of the study team.

Thank you.

First name:
Last name:
Email address:
Phone


Address 1

Street

Address 2

Suburb

Address 3

City

Postcode

Notes

Do you have any questions you would like us to answer?
Basic screening

Are you male or female?



What is your date of birth?

dd/mm/yyyy
(dd / mm / yyyy)

Have you been limiting carbohydrate in your diet for 4 months or more?


If yes, please provide the date when you began limiting carbohydrate in your diet?

Have you been diagnosed with any of the following?

Tick all that apply to you







Please provide more details about the condition(s) you have been diagnoses with (including medications):

Have you undergone bariatric surgery? (e.g gastric bypass surgery, gastric band)


Are you pregnant or breastfeeding?




If you are breastfeeding, how long have you been breastfeeding for?

In order to fulfill our study requirements, it is critical that you as a volunteer can successfully complete all aspects of the study.

Are you willing to give a blood samples and a urine sample?


Email Address

Massey Contact Centre Mon - Fri 8:30am to 4:30pm 0800 MASSEY (+64 6 350 5701) TXT 5222 contact@massey.ac.nz Web chat Staff Alumni News Māori @ Massey