Alopecia 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 (or your child) been diagnosed with alopecia areata? *–Yes, myself (Adult)Yes, my childNoUnsure

3. Do you (or your child) have patchy hair loss that includes circular bald areas on your scalp? *–YesNoUnsure

4. Do you (or your child) have between 20-100% hair loss (not hair thinning)? *–Yes, 20% to 50% lossYes, greater than 50% lossNoUnsure

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 www.clinicaltrials.gov and search:

NCT07049328

NCT07733765
NCT07133308