Dawes Fretzin Dermatology
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Pyoderma Gangrenosum Application Form
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Name
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First
Last
Age
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Example: 3175165030
1. How did you find us?
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2. If you were referred by a staff member, please list name
3. Have you been diagnosed with pyoderma gangrenosum?
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4. Do you have at least one active ulcer ≥5 cm² in size?
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Yes
No
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5. Have you used oral steroids to treat your pyoderma gangrenosum?
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Yes
No
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6. Have you used topical medications to treat your pyoderma gangrenosum?
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