Children's Study

1
Your Full Name* This field is required.
First Name
Last Name
2
Is your child aged between 2-8 years old?* This field is required.This is inclusive of 2 & 8
Yes
No
3
Hidden - Is your child aged between 2-8 years old?
Yes
No
4
Are they attending a daycare or school?* This field is required.
Yes
No
5
Hidden - Are they attending a daycare or school?
Yes
No
6
Have they been diagnosed with any medical conditions?* This field is required.
Yes
No
7
Hidden - Have they been diagnosed with any medical conditions?* This field is required.
Yes
No
8
Please specify what medical conditions they have been diagnosed with* This field is required.
9
Are they currently taking any medications or supplements?* This field is required.including any multivitamins, probiotics or prebiotics
Yes
No
10
Hidden - Are they currently taking any medications or supplements?* This field is required.
Yes
No
11
Please specify what medications or supplements they are currently taking* This field is required.
12
Have they been diagnosed with any allergies or intolerances by a doctor or healthcare professional?* This field is required.i.e. seasonal, medication, or food allergies, or intolerances like to gluten or lactose
Yes
No
13
Hidden - Have they been diagnosed with any allergies or intolerances by a doctor or healthcare professional?* This field is required.
Yes
No
14
Please specify which allergies or intolerances they have* This field is required.i.e. seasonal, medication, or food allergies, or intolerances to gluten, lactose
15
Phone Number* This field is required.
087/021
1234567
16
Email* This field is required.For contact regarding this study
example@example.com
Confirm Email
17
Would you like to be subscribed to Atlantia's database?* This field is required.If you elect to be part of our database, you may be notified of future studies that Atlantia is undertaking that may be of interest to you. All communications to our database are undertaken in accordance with our Privacy Notice available at: https://atlantiaclinicaltrials.com/privacy-notice.
Yes, Subscribe Me
No, thank you.
18
Consent to mailing list - hidden* This field is required.
19
Where did you hear about the study?* This field is required.
Instagram
Facebook
Email
Previous Participant
School
Creche
Family/Friend
Google Search
Website Ad
Flyer
20
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 for the purpose of assessing your eligibility for this trial
21
Score* This field is required.
22
Reason* This field is required.
23
Form Status* This field is required.
Should be Empty: