Episodic Migraine Clinical Trials

Do you consent to the collection and processing of your personal data (including information about your race and ethnicity (as applicable), and your health information, including symptoms, diagnoses, medications, and treatments and our sharing of this information (“Health Data”) for the purpose of recruitment into clinical research studies, determining your eligibility for studies, and provision of other services you requested, and disclosure to our Research Partners? You may withdraw your consent at any time by contacting us at info@autocruitment.com. Please note that your revocation will not impact any records or health data already collected, disclosed, or processed based on your consent. If you do not consent to the collection and use of your Health Data in this manner, we will not be able to provide you with our services or evaluate your eligibility to participate in the studies. *

Yes

First Name *

Last Name *

Phone Number *

Email *

Date of Birth MM/DD/YYYY *

Zip Code *

What sex were you assigned at birth? *

Male

Female

Prefer not to say

Do you have history of experiencing migraine? *

Yes - I have history of migraine 

No

Have you been diagnosed (by a doctor) with any other medical conditions? *
For example: HIV, Hepatitis B, Hepatitis C, dementia, Alzheimer's Disease, epilepsy, seizure, stroke, Schizophrenia, inflammatory bowel disease (including Crohn's disease), ulcerative colitis, chronic liver disease, non-alcoholic fatty liver disease, liver cirrhosis, renal failure, fibromyalgia.
Please list here or write 'none'. 
Please only include conditions which have been diagnosed by a doctor.

Are you taking any other medications for any health conditions? *

Please, enter your height below. *

How much do you weigh in Lbs (pounds)? *

Which racial or ethnic group(s) do you identify with? *
Capturing information on ethnic backgrounds allows us to better understand how different groups may have different needs.
Please select all that apply.

What is the best day/time to reach you via telephone (we know you are busy)? *

Do you consent to receive recurring messages at the phone number you provided above, including SMS/MMS text messages, sent by or on behalf of AutoCruitment through the use of an autodialer or artificial intelligence with information about research studies for which you may be eligible? To opt out, reply “STOP”. For customer care or support, text “HELP”. Message and data rates may apply. Message frequency varies. By clicking “Yes”, you also agree to our SMS Terms and Privacy Policy. *

Yes No

Consent for Medical Records Retrieval

By selecting “Yes” and submit below, you consent to our use and disclosure of your personal information as necessary to obtain a copy of your electronic medical records, including but not limited to your medical history, test results, treatment plans, diagnoses, prescriptions, and any other information contained in those records as necessary to provide our services to you. This medical record information will be shared with our service providers and clinical research sites in order to provide our services, including to determine your eligibility for clinical research studies. *

You may withdraw your consent at any time by contacting us at info@autocruitment.com. Please note that your revocation will not impact any records or health data already collected, disclosed or processed based on your consent.

Yes No

The information you are providing here will be processed in accordance with our Privacy Policy, which describes our data privacy practices, including how we share your information with our Research Partners and use your information to send you details about potential clinical trial opportunities. When you submit this information, you consent to AutoCruitment’s use of your data as described in our Privacy Policy. If you have any questions regarding the handling of the information you have provided to AutoCruitment, or if you would like to make any changes or withdraw your consent, please contact us at info@autocruitment.com.

Episodic Migraine Clinical Trials

Study benefits include:

You may qualify if you: