CVD + Obesity 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

Have you been diagnosed (by a doctor) with any of the following medical conditions? *
Please select all that apply.

Have you previously had a revascularization procedure (PCI or GABG)? *
A revascularization procedure helps restore the limited or blocked blood flow to parts of the heart.

Yes - revascularization procedure

No

Unsure

Have you been diagnosed with or experienced heart attack, stroke, peripheral artery disease or had a revascularization procedure in the past 2 months? *

Yes - heart attack/stroke/peripheral artery disease/revascularization procedure in past 2 months

No

Unsure

Do you currently smoke? *

Yes - currently smoke

No

Have you taken any of the following medications? *
Please select all that apply.

Thiazide diuretics (E.g. Microzide® / Esidrix® / Aquazide H® / Thalitone® / HemiClor® / Zaroxolyn® / Diuril® / etc.)

Loop diuretics (E.g. Lasix® / Furoscix® / Bumex® / Demadex® / Soaanz® / Edecrin® / etc.)

Unsure

None of the above

Have you taken a statin medication for longer than 28 days? *
A statin medication is used to help lower cholesterol levels in the blood. (Examples include: Lipitor®, Crestor®, Zocor®, Pravachol®, Mevacor®, Livalo®)

Yes - statin medication taken for longer than 28 days

No

Unsure

Have you taken a weight loss medication (such as a GLP-1) in the last 3 months or plan to take a weight loss medication in the next few months? *
(Example: Trulicity®, Victoza®, Saxenda®, Ozempic®, Rybelsus®, Mounjaro®, Zepbound™) 

Yes - weight loss medication in the last 3 months

Yes - planning to take weight loss medication in the next few months

No

Have you been diagnosed (by a doctor) with any other medical conditions? *
(Examples include: sarcoidosis, amyloidosis, diabetic maculopathy, chronic pancreatitis, medullary thyroid carcinoma (MTC) multiple endocrine neoplasia syndrome type 2 (MEN-2), major depressive disorder (MDD), pheochromocytoma, Cushing syndrome, aortic coarctation, liver cirrhosis)
Please list here or write 'none.’  
Please only include conditions which have been diagnosed by a doctor.

Are you taking any medications for your health conditions? *
Please list them below or type ‘none’.

Please, enter your height below. *

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

Which racial or ethnic group(s) do you identify with? *
Please select all that apply.

Capturing information on ethnic backgrounds allows us to better understand how different groups may have different needs.

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

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.

CVD + Obesity Clinical Trials

Help us research study medications that may treat and prevent heart disease

Study benefits include:

Clinical trial participants must be: