Discoid Lupus 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 discoid lupus for at least 6 months? *–YesNoUnsure

4. Do you currently have active discoid lupus lesions? *–YesNoUnsure

5. Have you used or are you currently using a systemic therapy to treat your discoid lupus? *–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/NCT05591222?term=NCT05591222&rank=1