Chronic Pruritus of Unknown Origin 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. If you were referred by a staff member, please list name

3. Do you have a diagnosis of chronic pruritus of unknown origin for more than 6 months? *–YesNoUnsure

4. Have you previously used medications to try to control your itch without success? *–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/NCT07074977?term=SPR207913&rank=1