Clinical Study Participation Form

First Name

Last Name

Date of Birth

MM/DD/YYYY

Sex (assigned at birth)

FemaleMale

Zip Code

State

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Using the infographic above, which of the following best describes you

PremenopausePerimenopause/MenopausePost-menopause

Have you had problems with or are experiencing the following?

Hot flushes or flashesSleep DisturbancesDecreased libidoVaginal odorMuscle tension & achesFatigueDepressionSexual healthEndometriosisBacterial VaginosisNight sweatsMood Changes (irritability)Thinning or brittle hairJoint painBrittle nailsAnxietyPainful urinationIrritable Bowel SyndromePCOSIron DeficiencyOver-active bladderVaginal drynessSkin issuesIrregular periodsWeight gainOsteopenia, osteoporosis (bone loss)Breast painGastrointestinal DiscomfortRecurrent UTIsOther:

What other problems are you experiencing?:

Are you interested in virtual clinical and experience research trials where you can test products from your home?

YesNoI am not sure; I would like more information

Are you interested in learning about in-person or hybrid (in-person and virtual) clinical trials at research clinics close to your home?

YesNoI am not sure; I would like more information

What types of research studies are you interested in?

Hot Flash StudiesSleep StudiesVaginal Dryness StudiesVaginal Odor StudiesRecurrent UTI StudiesMood StudiesSkin/Hair/Nails StudiesIron Deficiency StudiesOveractive Bladder StudiesSexual Health StudiesIrritable Bowel Syndrome StudiesOther:

What other types of research are you interested in?:

If you currently use Bonafide product(s), please select which products you use.

ClairveeSerenolRelizenVitamin DMagnesium ComplexZincRistelaRevareeThermellaVitamin B ComplexCalcium + Vitamin DI do not use Bonafide productsSilvessaRevaree PlusMulti VitaminGut ProbioticVitamin C

Email

Phone Number

Does Bonafide Health have your consent to text the provided phone number?

YesNo

Does Bonafide Health have your consent to message the email you provided?

YesNo

How did you hear about Bonafide Clinical Studies?

I’m an active Bonafide subscriber/customerI’m a former Bonafide subscriber/customerI’ve never used Bonafide productsSocial media – FacebookSocial media– InstagramBlog or publicationA podcast appTV or RadioRecommendation from a friend/colleagueBrochure/flyerDoctor referralOther:

Other: