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

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

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

How would you describe the skin texture on both of your cheeks? *

4 - Extremely rough or uneven on both cheeks (Skin feels very rough or bumpy or uneven across most of both cheeks. You may notice pronounced texture or flaking or patchiness)

3 - Severely rough or uneven on both cheeks (Skin feels clearly textured or uneven when you touch it or with noticeable bumps or rough areas on both cheeks)

2 - Moderately rough or uneven on both cheeks (Skin is mostly smooth but has mild unevenness or small bumps or slight dryness in some areas of both cheeks)

1 - Smooth and even on both cheeks (no roughness)

Referring to the skin tone image guide and the sun tan/burn descriptions provided on this page, please select the option that most closely matches your skin. *

Type 6 - Never burns / tans very easily / deeply pigmented

Type 5 - Rarely burns / tans well

Type 4 - Burns minimally / always tans to moderate brown

Type 3 - Sometimes burns / slowly tans to light brown

Type 2 - Burns easily / tans minimally

Type 1 - Always burns / never tans

In the past 2 years, have you had any temporary facial fillers in your cheeks, jawline, or lower face (e.g. Juvéderm®, Restylane®, Belotero®, Radiesse®, or collagen fillers)? *

Yes - temporary fillers in cheek/jawline/lower face in last 2 years

No

In the past 3 years, have you had any semi-permanent facial fillers (Sculptra®, Radiesse®, or similar products)? *

Yes - semi-permanent fillers in last 3 years

No

In your lifetime, have you had fat injections or permanent implants to your face? *

Yes - fat injections or permanent implants on face

No

Are you taking any other medications or treatments for your health conditions? *
Please list them below or type ‘none’. (Examples: warfarin (Coumadin®), clopidogrel (Plavix®))

Have you been diagnosed (by a doctor) with any other medical conditions or had related procedures? *
Please list them below or type ‘none’. (Examples: HIV, Hep B, Hep C, Cancer, history of anaphylactic shock, anaphylaxis, severe allergic reactions, LASIK eye surgery)

Are you currently pregnant, breastfeeding, or planning to become pregnant in the next 12 to 16 months? *

Yes - pregnant / breastfeeding / planning to become pregnant

No

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

American Indian or Alaskan Native

Asian

Black or African American

Hispanic or 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

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)? *

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.