Cutaneous T-Cell Lymphoma Application Form

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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. Have you been diagnosed with CTCL? *–YesNoUnsure

3. Do you currently have at least 3 active CTCL lesions? *–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: https://clinicaltrials.gov/study/NCT06470451?term=hpn-ctcl-03-eur&rank=1