First Name *

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Last Name *

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Phone Number *

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Email *

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Date of Birth MM/DD/YYYY *

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Zip Code *

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What sex were you assigned at birth? * Please select one... Male Female Prefer not to answer

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Are you able to read, speak, and understand English? * Please select one... Yes No

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Do you normally wear corrective lenses, contacts, or glasses to read? *
If yes, you will need to have them available during your interview in order to participate. Please select one... Yes No

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Have you ever participated in a research study about a medicine for erectile dysfunction? * Please select one… Yes No

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Have you participated in another health-related market research study, product label study, or clinical trial in the past 12 months? * Please select one... Yes No

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Do you, or does anyone in your household work for a pharmaceutical, marketing research, or an advertising company? * Please select one... Yes No

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Are you, or is anyone in your household a healthcare professional, trained as a healthcare professional, or working as part of a healthcare practice? * Please select one... Yes No

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Are you or is anyone else in your household employed by PEGUS Research? * Please select one... Yes No

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Do you have a laptop, desktop computer, smartphone, or tablet with a video camera you use to access the internet regularly? * Please select one... Yes No

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

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By checking this box, I agree to receive SMS messages from PEGUS Research at the phone number provided. Msg and data rates may apply. Msg frequency varies. Please see the PEGUS Messaging Terms and Conditions and the PEGUS Privacy Notice for more information. READ THE TERMS AND CONDITIONS *

Yes

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I was given the opportunity to review the PEGUS Privacy Notice. READ THE PEGUS PRIVACY NOTICE *

Yes

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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. By providing your phone number and clicking “Submit” below, you consent to receive messages, including SMS/MMS text messages, sent by or on behalf of AutoCruitment, with information about research studies for which you may be eligible. By clicking Submit, you also agree to our SMS Terms. 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.

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