Dawes Fretzin Dermatology
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Hand/Foot Dermatitis Application Form
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Name
*
First
Last
Age
*
Email
*
Phone Number
*
Example: 3175165030
1. How did you find us?
*
–
Physician
Staff Referral
Friend or Family
Social Media
Office Flyer
Other
2. If you were referred by a staff member, please list name
3. Have you been diagnosed with hand/foot dermatitis?
*
–
Yes
No
Unsure
4. Do you have active hand/foot dermatitis on at least 2 of the 4 possible locations? (Right Hand, Left Hand, Right Foot, Left Foot)
*
–
Yes
No
Unsure
5. Do you have atopic dermatitis (eczema) on other areas of your body?
*
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Yes
No
Unsure
6. Have you used topical medications to treat your hand/foot dermatitis?
*
–
Yes
No
Unsure
7. Have you used systemic medications to treat your hand/foot dermatitis? (copy)
*
–
Yes
No
Unsure
Submit
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