Atopic Dermatitis Study Application

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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. Do you have a diagnosis of atopic dermatitis/eczema? *–YesNoUnsure

4. At what age were you diagnosed with atopic dermatitis/eczema?

5. Do you have active atopic dermatitis/eczema on your body? *–YesNoUnsure

6. Where is your atopic dermatitis/eczema currently located? (copy) *

7. Do you have atopic dermatitis/eczema covering at least 10% of your body? *–YesNoUnsure

10% is about the size of 2 sheets of paper when all your active atopic dermatitis/eczema lesions are combined.

8. Have you previously used a prescription biologic (injectable) therapy to treat your atopic dermatitis/eczema? *–YesNoUnsure

9. Have you previously used a prescription topical therapy to treat your atopic dermatitis/eczema? *–YesNoUnsure

10. Do you suffer from sleep loss due to itching from your atopic dermatitis/eczema? *–YesNoUnsure

Submit

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

For additional information on these studies, please visit:

https://clinicaltrials.gov/study/NCT05696392?term=NCT05696392&rank=1

https://clinicaltrials.gov/study/NCT05923099?term=NCT05923099&rank=1

https://clinicaltrials.gov/study/NCT06224348?term=NCT06224348&rank=1

https://clinicaltrials.gov/study/NCT06241118?term=NCT06241118&rank=1

https://clinicaltrials.gov/study/NCT05704738?term=NCT05704738&rank=1