Alopecia Topical Study Survey

Therapeutics Clinical Research is conducting a clinical research study for an investigational topical medication for males experiencing hair thinning. In order to determine if you pre-qualify for this study, we will ask you a few questions about your condition. You may stop answering at any time and you do not need to answer any questions that make you feel uncomfortable.

All information you provide will be kept strictly confidential and will not be shared without your permission, except as required by law. Please feel free to call us for more information at (858) 571-6800.

By providing your contact information, you agree to receive phone calls, emails and/or texts from Therapeutics Clinical Research.

1.Tell us about yourself:(Required.)

Name:

Email Address:

Phone Number:

2.Are you a male between the ages of 18 and 55 years old?

Yes

N/A I am female

3.Have you been experiencing hair thinning?

Yes

4.Do you use any nicotine products?

Yes

5.Are you otherwise in good general health with no major medical conditions?

Yes

No (please list medical conditions):

Thank you for completing the survey. We will review your information and contact you shortly. If you would like additional information or would like to speak to a staff member directly, please feel free to call us at (858) 571-6800.

Current Progress,

0 of 6 answered