Fields marked with an * are required.

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 answer

Has a doctor diagnosed you with Sjögren’s Disease? *
Sjögren’s Disease is an autoimmune disorder that causes dry eyes and dry mouth.

Yes - diagnosed by a doctor with Sjögren’s Disease

No

Unsure

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

Common Variable Immunodeficiency (CVID)

HIV

Lymphoma

Tuberculosis

None of the above

Have you been diagnosed (by a doctor) with any other medical conditions? * 
(For Example: Rheumatoid arthritis, systemic sclerosis, SLE, gout, inflammatory bowel disease, hepatitis, Fibromyalgia, Herpes, etc.)
Please list here or write 'none'. 
Please only include conditions which have been diagnosed by a doctor.

Do you have a history of any of the following treatments? *
Please select all that apply...

Splenectomy (spleen removal)

Solid organ transplant (ex.heart/liver/kidney/lung/pancreas)

Bone marrow transplant

Stem cell therapy or transplant

None of the above

Are you taking any medications or treatments for Sjogren’s Disease or other health conditions? *
(For Example: cyclophosphamide, cyclosporine, Chloroquine, Rituximab, belimumab, abatacept, etanercept, infliximab, anakinra, Cytoxen®, Neoral®, Rituxan®, Benlysta®, Orencia®, Enbre®l, Erelzi®, Remicade®, Renflexis®, Kineret®, Alaren®, Resochin®)
Please list them below or type ‘none’.

Are you willing to self-administer an injection, or have a personal caregiver administer it for you? *

Yes - willing to self administer injection

No - but is willing to come on-site for weekly injections

No - and is not willing to come on-site for weekly injections

Unsure - I'd like to speak to the site staff

Are you allergic to any human-derived products (products made from human blood)?

Yes - I'm allergic to human derived products

No

Not sure

Are you currently breastfeeding, pregnant or planning to become pregnant in the next 16 months? *

Yes

No

Not Applicable

Are you currently using any birth control or contraceptive method (such as pills, injections, IUD, implants)?

Yes No

Which racial or ethnic group(s) do you identify with? * 
Capturing information about ethnic backgrounds helps us ensure that the study reflects the experiences of many different communities and supports a better understanding of their unique health needs.
Please select all that apply.

American Indian or Alaskan Native

Asian

Black or African American

Hispanic Latino or Spanish

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

White

Mediterranean (Greek/Italian/Portuguese/Spanish/etc.)

Another race or ethnicity

I prefer not to answer

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

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

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.