Psoriasis 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. Do you (or your child) have a diagnosis of psoriasis? *–YesNoUnsure

4. Do you (or your child) have active psoriasis on your body? *–YesNoUnsure

5. Where is your (or your child’s) psoriasis currently located? *

6. Do you (or your child) have psoriasis covering at least 10% of your body? (10% is about the size of 2 sheets of paper) *–YesNoUnsure

10% is about the size of 2 sheets of paper

7. Have you (or your child) previously used a prescription biologic (injectable) therapy to treat your psoriasis? *–YesNoUnsure

8. Have you (or your child) previously used a prescription oral therapy to treat your psoriasis? *–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/NCT06979453?term=im011-1128&rank=1

https://clinicaltrials.gov/study/NCT07116967?term=im011-1130&rank=1