Fields marked with an * are required.

Would you like to be contacted about taking part in a Clinical Trial that the child may be eligible for? *

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 only be used to match your child to a clinical research study in the potential participant’s area and contact you to see if you would like for your child 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

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