Chronic Spontaneous Urticaria Application Form

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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. Do you have a diagnosis of symptomatic CSU for more than 6 months? *–YesNoUnsure

3. Have you had the presence of itch and hives for more than 8 consecutive weeks despite current use of H1-antihistamines? *— Select Choice —YesNoUnsure

4. Are you currently taking a stable dose of H1-antihistamines? *–YesNoUnsure

5. Have you previously used omalizumab (Xolair)? *–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/NCT06931405?term=blu-808-1201&rank=1