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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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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 or Postal Code *

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What do you identify your sex as? Please select one... Female Male Prefer not to say

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Have you been diagnosed by a doctor with systemic lupus erythematosus (SLE)? *

Systemic lupus erythematosus (SLE) is an autoimmune disease where the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs.

Please select one... Yes – Systemic Lupus Erythematosus (SLE) No Unsure

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When did you receive your lupus diagnosis? * Please select one… 0-4 months ago 5 months ago More than 6 months ago Unsure

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Are you currently/regularly taking a prescribed medication for your systemic lupus erythematosus (SLE) treatment? *
This may include immunosuppressant or antimalarial medications such as Imuran® (azathioprine), Purinethol® (6-mercatopurine), methotrexate, Arava® (leflunomide), tacrolimus, mizoribine, CellCept® (mycophenolate mofetil), Myfortic® (mycophenolic acid), Aralen® (chloroquine), Plaquenil® (hydroxychloroquine), or Mepacrine (quinacrine).
*Please note: This is not a full list of available lupus medications. Please select one... Yes No Unsure

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How long have you been taking the above prescribed medication for your systemic lupus erythematosus (SLE) treatment? * Please select one… Less than 1 month 1 – 2 months 3 months or longer

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Have you been diagnosed (by a doctor) with any other medical conditions? *

(For example: multiple sclerosis (MS), psoriasis, inflammatory bowel disease, rheumatoid arthritis (RA), scleroderma, mixed connective tissue disease, cancer, tuberculosis (TB), fibromyalgia, chronic fatigue syndrome, chronic pain syndrome, catastrophic antiphospholipid syndrome (CAPS), heart failure)

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 lupus or other health conditions? *

(For example: topical steroids, Sotyktu™, deucravacitinib, ropsacitinib, brepocitinib, interferon alpha kinoid, cell therapy, Chinese traditional medicine – glucoside of peony, tripterygium glycosides, botanical preparations)

Please list them below or type ‘none’.

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If person of childbearing potential, are you currently pregnant, breastfeeding? * Please select one… Yes No N/A- Not a person of childbearing potential

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If person of childbearing potential, are you using, or willing to use, birth control for the duration of the study? * Please select one… Yes No N/A- Not a person of childbearing potential

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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 Latino or Spanish

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

White

Another race or ethnicity

I prefer not to answer

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

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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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