Alopecia Study Application

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Name *

First

Last

Age *

Email *

Phone Number *

Example: 3175165030

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

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

3. Have you (or your child) been diagnosed with alopecia areata? *–Yes, myself (Adult)Yes, my childNoUnsure

4. Do you (or your child) have patchy hair loss that includes circular bald areas on your scalp? *–YesNoUnsure

5. Do you (or your child) have between 20-100% hair loss (not hair thinning)? *–Yes, 20% to 50% lossYes, greater than 50% lossNoUnsure

Submit

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

For additional information on this study please visit:
https://clinicaltrials.gov/study/NCT06602232?term=dr-01-aim-001&rank=1
https://clinicaltrials.gov/study/NCT07029711?term=b7981027&rank=1
https://clinicaltrials.gov/study/NCT07133308?term=cp543.3101&rank=1