Chronic Inducible Urticaria 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. Have you been diagnosed with dermatographism or cold urticaria? *–YesNoUnsure

4. Does a hive form on your skin when pressure is applied to your skin or when your skin is scratched? *–YesNoUnsure

5. Does a hive form on your skin when it is exposed directly or indirectly to cold? *–YesNoUnsure

6. Have you ever received the prescription therapy Xolair for the treatment of your hives? *–YesNoUnsure

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