Gum Health Study

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Full Name* This field is required.
First Name
Last Name
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Please enter your age* This field is required.
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Hidden - Form Value
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Hidden - Age Pass/Fail
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Are you currently pregnant, breastfeeding or planning a pregnancy?* This field is required.
Yes
No
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Hidden - Are you currently pregnant, breastfeeding or planning a pregnancy?
Yes
No
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How often do you perform oral hygiene, on average?* This field is required.i.e. brushing, flossing, etc
More than 2 times per day
2 times per day
1 time per day
Less than 1 time per day
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Hidden - How often do you perform oral hygiene?* This field is required.
More than 2 times per day
2 times per day
1 time per day
Less than 1 time per day
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How often do you gums bleed when performing dental hygiene?* This field is required.
Daily
5-6 days per week
3-4 days per week
1-2 days per week
Less than 1 day per week
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Hidden - How often do you gums bleed when performing oral hygiene?* This field is required.
Daily
5-6 days per week
3-4 days per week
1-2 days per week
Less than 1 day per week
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Have you or are you currently undergoing any dental intervention* This field is required.
Yes
No
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Hidden - Have you or are you currently undergoing any dental intervention* This field is required.
Yes
No
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Please specify what dental treatment you are undergoing* This field is required.
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Have you used any teeth whitening or bleaching products in the last 3 months?* This field is required.
Yes
No
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Hidden - Have you used any teeth whitening or bleaching products in the last 3 months?
Yes
No
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Have you been diagnosed with any medical conditions?* This field is required.e.g. High blood pressure, high cholesterol, ulcerative colitis, coeliac disease, etc
Yes
No
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Hidden - Have you been diagnosed with any medical conditions* This field is required.e.g. High blood pressure, high cholesterol, ulcerative colitis, coeliac disease, etc
Yes
No
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Please specify what medical conditions you have been diagnosed with* This field is required.e.g. High blood pressure, high cholesterol, ulcerative colitis, coeliac disease, etc.
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Are you currently taking any medications or supplements?* This field is required.e.g blood pressure/cholesterol meds, multivitamins, probiotics or prebiotics
Yes
No
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Hidden - Are you currently taking any medications or supplements?* This field is required.
Yes
No
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Please specify what medications or supplements you are currently taking* This field is required.If you are not sure about the name, you can put down what the medication is used for, e.g. high blood pressure
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Phone Number* This field is required.
Please enter a valid phone number.
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Email* This field is required.For contact regarding this study
example@example.com
Confirm Email
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Would you like to be subscribed to Atlantia's database?* This field is required.Subscribing to this allows us to contact you occasionally via email with study updates or new studies
Yes, Subscribe Me
No, thank you.
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Consent to mailing list - hidden* This field is required.
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Where did you hear about the study?* This field is required.
Instagram
Facebook
Email
Website Ad
Family/Friend
Previous Participant
Google Search
Flyer
Other
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Consent to Privacy Notice* This field is required.We need your explicit consent to process the personal data collected as part of this form in particular, health data. All personal data relevant to pre-screening for trials is processed in accordance with our Privacy Notice. You can withdraw consent by contacting us at dataprotectionofficer@atlantiatrials.com Do you consent to Atlantia Food Clinical Trials Ltd. processing the information you have provided in this form for the purpose of assessing your eligibility for this trial
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Score* This field is required.
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Reason* This field is required.
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Form Status* This field is required.
Should be Empty: