Androgenetic Alopecia Study Application

Please enable JavaScript in your browser to complete this form.

Name *

First

Last

Age *

Email *

Phone Number *

Example: 3175165030

1. How did you find us? *–PhysicianStaff ReferralFriend or FamilySocial MediaOffice FlyerOther

2. If you were referred by a staff member, please list name

3. At what age did your balding begin? *

4. Are you currently using any topical or oral treatments for your hair loss? *–YesNo

5. Do you currently have a receding hairline in a the frontal area AND thinning hair on the crown of your head? *–YesNo

Submit

By submitting your information, you give Dawes Fretzin Clinical Research Group permission to contact you regarding study opportunities.