Pyoderma Gangrenosum Application Form

Please enable JavaScript in your browser to complete this form.

Name *

First

Last

Age *

Email *

Phone Number *

Example: 3175165030

1. How did you find us? *–PhysicianFriend or FamilySocial MediaOffice FlyerOther

2. If you were referred by a staff member, please list name

3. Have you been diagnosed with pyoderma gangrenosum? *–YesNoUnsure

4. Do you have at least one active ulcer ≥5 cm² in size? *–YesNoUnsure

5. Have you used oral medications or oral steroids to treat your pyoderma gangrenosum? *–YesNoUnsure

6. Have you used topical medications or topical steroids to treat your pyoderma gangrenosum? *–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:
https://clinicaltrials.gov/study/NCT06624670?term=1368-0140&rank=1