Vitiligo 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 vitiligo? *–YesNoUnsure

4. Do you have vitiligo on your face? *–YesNoUnsure

5. Do you have vitiligo on your body? *–YesNoUnsure

6. Have you used topical medications to treat your vitiligo? *–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/NCT06118411?term=NCT06118411&rank=1

https://clinicaltrials.gov/study/NCT06113328?term=NCT06113328&rank=1