Fields marked with an * are required.

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.

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

{{ error }}

First Name *

{{ error }}

Last Name *

{{ error }}

Phone number *

{{ error }}

Email 

{{ error }}

Date of Birth MM/DD/YYYY *

{{ error }}

ZIP or Postal Code *

{{ error }}

Are you Male or Female? Please select one... Female Male Prefer not to say

{{ error }}

Have you been diagnosed (by a doctor) with Multiple Sclerosis (MS)? * Please select one Yes – I have Multiple Sclerosis No

{{ error }}

Have you had at least 1 Multiple Sclerosis relapse in the past year, or 2 relapses in the past 2 years, for which you visited a doctor? *
A Multiple Sclerosis relapse is a worsening of your symptoms or appearance of new symptoms lasting more than 24 hours before fully or partially recovering. Please select one... Yes No Unsure

{{ error }}

Are you able to walk at least 100 meters without rest or assistance (such as a cane, crutch, or other walking aid)? * Please select one... Yes No

{{ error }}

Have you been diagnosed (by a doctor) with any other medical conditions? *
(For example: cancer, cardiomyopathy, schizophrenia, gout, lupus, rheumatoid arthritis, epilepsy).
Please list here or write 'none'.
Please only include conditions which have been diagnosed by a doctor.

{{ error }}

Are you taking any medications for your Multiple Sclerosis or other health conditions? *
Please list them below or type ‘none’.

{{ error }}

If female, are you currently pregnant, breastfeeding, or planning to become pregnant? Please select one... Yes No N/A- Male

{{ error }}

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

{{ error }}

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

{{ error }}