Atopic Dermatitis (Eczema) Clinical Trial Prescreening

1

Participants who qualify receive:

Study treatment at no cost
Compensation for their time and travel expenses
Uber transportation to and from study visits, if needed

2

Do you currently have eczema or atopic dermatitis?* This field is required.

Yes

No

3

About how long have you had eczema or atopic dermatitis?* This field is required.

Less than 6 months

More than 6 months

4

Have you ever seen a doctor or other healthcare provider for your eczema or atopic dermatitis?* This field is required.

Yes

No

5

About what percent of your skin is covered by eczema today? One handprint (your entire palm and fingers) equals about 1% of your skin. Count how many handprints of eczema you have on your body and enter that number.* This field is required.

6

Percentage Value (Do Not Delete)

7

Could you come to study visits about twice a month for the first few months, and then about once a month after that? The office is located at 📍 16100 NE 16th Ave, North Miami Beach, FL 33162

Yes

No

8

Calculation (Do Not Delete)

9

Thank you very much for participating in this survey. Based on your answers, we believe that you may be ineligible for this clinical trial. However, if you would like a staff member to contact you, please provide your best contact information below.

10

Full Name* This field is required.

First Name

Last Name

11

Email Address* This field is required.

example@example.com

12

Cell Phone Number* This field is required.

Please enter a valid phone number.

13

Best Time to Contact You* This field is required.