Androgenetic 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. At what age did your balding begin? *

3. Are you currently using any topical or oral treatments for your hair loss? *–YesNo

4. Do you currently have a receding hairline in the frontal area AND thinning hair on the crown AND part of your head? *–YesNo

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