Vitiligo 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. Have you been diagnosed with vitiligo? *–YesNoUnsure

3. Do you have vitiligo on your face? *–YesNoUnsure

4. Do you have vitiligo on your body? *–YesNoUnsure

5. Have you used topical medications to treat your vitiligo? *–YesNoUnsure

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 www.clinicaltrials.gov and search:

NCT07533019