Lichen Planopilaris 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 lichen planopilaris? *–YesNoUnsure

3. Have you experienced at least one symptom of lichen planopilaris (pruritus, burning, pain, tingling, tenderness)? *–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:

NCT07532603