Fields marked with an * are required.

Do you consent to the collection and processing of your personal data (including information about your health, race and ethnicity (as applicable); including disclosure to our Research Partners) for the purpose of recruitment into clinical research studies? *

Yes

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If you are under the age of 13 (or 16 if you are in California or in Europe), you may not directly enter any information and your legal parent or guardian must enter this information on your behalf. By filling out this form, you are confirming that you meet these requirements.

Who are you interested in this study for? * Please select one... My Child Other

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Child’s First Name *

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Child’s Last Name *

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Child’s Date of Birth MM/DD/YYYY *

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Child’s Zip Code or Postal Code *

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Is the child Male or Female?
Please select one... Female Male Prefer not to say

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Has the child been experiencing constipation? *
Symptoms of constipation may include:

• Infrequent bowel movements
• Hard stool
• Painful defaecation
• Abdominal pain

Please select one… Yes – the child has constipation No

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On average, how many bowel movements per week (7 days) does the child experience? * Please select one... 2 or less bowel movements per week 3 or more bowel movements per week

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Does the child require use of laxatives, suppositories, or enemas to have bowel movements? * Please select one... Yes No

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How often is the use of laxatives, suppositories or enemas used to initiate bowel movement? Please select one... Once a week Twice a week Daily

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Has the child been diagnosed with any other medical conditions? *
Please list here or write 'none'.
Please only include conditions which have been diagnosed by a doctor.

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First Name of parent/legal guardian to contact *

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Last Name of parent/legal guardian to contact *

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Phone Number of parent/legal guardian to contact *

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Email of parent/legal guardian to contact

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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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