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18 August, 2026 8:00 AM Free

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3 October, 2026 8:00 AM Free

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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.

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.

Screening Form Alopecia

Subscribe

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.

Screening Form Vitiligo

Notify

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.

Screening Form Vitiligo

Contact

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.

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