Lichen Planus 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. Have you been diagnosed with lichen planus? *–YesNoUnsure

3. Do you have at least 2 body regions affected by lichen planus? *–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 www.clinicaltrials.gov.