Healthy Participant Study

Are you interested in participating in clinical research?

Would you like to take part in a Clinical Research Study for a new investigational medication for healthy adults at no cost to you and be compensated?

Sign up and we will notify you of clinical trials in your area that need healthy patients.

No health insurance is required to participate. The study will involve a 5-night stay and visits to the study center.

Sign up to take part in a clinical trial.

What happens if I sign up?

You may be eligible for a clinical research study for healthy adults, also known as a clinical trial in your area. Someone from the study team or study center conducting the trial will contact you to explain more about this research study before you make your decision about participating.

Sign Up

Fields marked with an * are required.

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.

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 for the purpose of recruitment into clinical research studies, determining your eligibility for studies, and provision of other services you requested? *
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

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Personal Information

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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Are you Male or Female? *

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Health History

How would you rate your overall health? *

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

Cluster headaches and/or tension headaches

Migraine

Diabetes

Hyperthyroidism

Hypothyroidism

Hypertension/high blood pressure

Increased risk of bleeding/coagulation disorder (example: hemophilia/ Von Willebrand disease/ clotting factor deficiencies/ deep vein thrombosis)

None of the above

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Do you suffer from chronic low back pain or have a history of a lower back condition? *
(For example: ankylosing spondylitis, scoliosis, dysraphism, prior back surgery)

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Are you currently experiencing frequent headaches? *
Frequent headaches occur more than once a week over the past 3 months.

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Have you been diagnosed (by a doctor) with any other medical conditions? *
(For example: kidney disease, liver disease).
Please list here or write 'none'.
Please only include conditions which have been diagnosed by a doctor.

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

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Are you currently taking a neuromodulator for pain management? *
Neuromodulators can be used for nerve pain or pain caused by nerve damage.
Please select one or more of the following:

Gabapentin (Horizant® / Gralise® / Neurontin®)

Pregabalin (Lyrica®)

Duloxetine (Cymbalta® / Irenka® / Drizalma Sprinkle®)

Unsure

None of the above

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Do you have an allergy, hypersensitivity, intolerance, or cannot use any local anesthetics, opioids, NSAIDs, or spinal anesthesia? *
(Local anesthetics include: lidocaine, EXPAREL®, Novocaine®, or bupivacaine)

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Do you have a history of illicit drug, prescription medicine, or alcohol abuse? *

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How long ago did your illicit drug, prescription medicine, or alcohol abuse end? *

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Additional Details

Please, select your height from the dropdown below. *

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

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If female, are you currently pregnant or breastfeeding? *

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Have you participated in a clinical trial for an investigational drug in the past 30 days? *

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

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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.

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