Birth Control Clinical Study

Fields marked with an * are required.

First Name *

Last Name *

Phone Number *

Date of Birth MM/DD/YYYY *

Zip Code or Postal Code *

Are you Male or Female? *

Have you had your first menstrual period? *

When you are not on birth control, on average, how often do you menstruate (get a period)? *

Are you sexually active, with a male partner, at least once a month? *

Are you interested in trying an investigational birth control patch? *

Would you be willing to use the investigational birth control patch for the duration of the study (12 months)? *

Are you currently using hormonal birth control (either pills, an IUD or an implant under your skin)? *

To participate in the study, would you be willing to discontinue use of your birth control pills or have your IUD or birth control implant removed for the duration of the study?
Please note, the study team will discuss this with you further if you qualify for the study. Barriers to protect against sexually transmitted infection, such as condoms or diaphragms may still be used.

Have you been diagnosed (by a doctor) with any medical conditions? *
Please list here or write 'none'
Please only include conditions which have been diagnosed by a doctor.

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

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

Please, select your height from the dropdown below. *

Are you currently pregnant or breastfeeding? *

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

Would you like to be contacted about taking part in a Clinical Research Study (also called a Clinical Trial)? *

Yes

The information you are providing here will only be used to match you or a loved one to a clinical research study in the potential participant’s area and contact you to see if you or a loved one would like to participate. Please note the information you enter will be kept private, except when ordered by law, and only accessible to our Clinical Research Partners and affiliates and applicable regulatory agencies. If you have any questions regarding the handling of the information you have provided to autocruitment.com, or if you would like to make any changes, please contact us at info@autocruitment.com.