Alopecia Study Application

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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. If you were referred by a staff member, please list name

3. Have you been diagnosed with alopecia areata? *–YesNoUnsure

4. Do you have patchy hair loss that includes circular bald areas on your scalp? *–YesNoUnsure

5. Do you have between 30-95% hair loss (not hair thinning)? *–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/NCT04582383?term=NCT04582383&rank=1