Prurigo Nodularis 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 prurigo nodularis? *–YesNoUnsure

3. Do you have prurigo nodularis lesions on at least 2 different body areas? *–YesNoUnsure

4. Do you have more than 20 lesions on your body? *–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 and search: NCT07236099