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Screening Form Atomic Dermatitis (Eczema)
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Atomic Dermatitis
Prequalification Form
Is your child between the ages of 1 and 12 years old?
Yes
No
Has your child been diagnosed with atomic dermatitis (Eczema)?
Yes
No
Not Sure
On a scale of 1 to 10, how much is the level of itchiness, being 1 moderate to 10 more severe?
1-3 Moderate Itch (Noticeable to distracting)
4-6 Intense Itch (Frequent scratching, constant urge, very distracting).
7-10 Severe Itch (Overwhelming).
Contact Info
Email
I consent to have this website store my submitted information so they can respond to my inquiry.
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Screening Form Atomic Dermatitis (Eczema)
Newsletter
Atomic Dermatitis
Prequalification Form
Is your child between the ages of 1 and 12 years old?
Yes
No
Has your child been diagnosed with atomic dermatitis (Eczema)?
Yes
No
Not Sure
On a scale of 1 to 10, how much is the level of itchiness, being 1 moderate to 10 more severe?
1-3 Moderate Itch (Noticeable to distracting)
4-6 Intense Itch (Frequent scratching, constant urge, very distracting).
7-10 Severe Itch (Overwhelming).
Contact Info
Email
I consent to have this website store my submitted information so they can respond to my inquiry.
Submit Form
CLOSE
Screening Form Alopecia
Newsletter
Pediatric Alopecia Prequalification Form
Choose an option according to your child age?
From 2 to 5 years old
From 6 to 11 years old
Has your teen been diagnosed with Alopecia Areata by a doctor?
Yes
No
Not Sure
How long has your teen had this current episode of hair loss?
Less than 6 months
6 months to 5 years
5 to 10 years
More than 10 years
Approximately how much of your teen's scalp hair has been lost?
Less than 50%
About half (50%)
More than 50%
Nearly all or all
Are you able to travel to our Miami, FL clinic for study visits?
Yes, easily
Yes, with some planning
Probably not. I need to know more
Are you able to travel to our Miami, FL clinic for study visits?
Yes, easily
Yes, with some planning
Probably not. I need to know more
Contact Info
Email
I consent to have this website store my submitted information so they can respond to my inquiry.
Submit Form
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Screening Form Vitiligo
Newsletter
Pediatric Vitiligo Prequalification Form
Is your child between the ages of 2 and 11 years old?
Yes
No
Has your child been diagnosed with nonsegmental vitiligo?
Yes
No
Not Sure
Is your child’s vitiligo limited to no more than 10% of their face and body?
Yes
No
Not Sure
Contact Info
Email
I consent to have this website store my submitted information so they can respond to my inquiry.
Submit Form
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Screening Form Vitiligo
Subscribe
Pediatric Vitiligo Prequalification Form
Is your child between the ages of 2 and 11 years old?
Yes
No
Has your child been diagnosed with nonsegmental vitiligo?
Yes
No
Not Sure
Is your child’s vitiligo limited to no more than 10% of their face and body?
Yes
No
Not Sure
Contact Info
Email
I consent to have this website store my submitted information so they can respond to my inquiry.
Submit Form
CLOSE
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