Prurigo Nodularis 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 prurigo nodularis? *–YesNoUnsure

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

5. Do you have lesions on about 25% of your body surface area? *–YesNoUnsure

25% is about the size of 4 sheets of paper

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/NCT06213831?term=NCT06213831&rank=1