Facial Acne Study Survey

Therapeutics Clinical Research is conducting a clinical research study for an investigational topical medication for people living with facial acne. 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:

Name:

Email Address:

Phone Number:

2.Are you 18 years of age or older? If not, is a legal guardian present?

Yes

Legal guardian is present

3.If female, are you pregnant, nursing, or planning to be pregnant?

Yes

N/A; I am male

4.How would you rate the severity of your facial acne?

Mild

Moderate

Severe

5.On average, how many pimples for you have on your dace any given day?

0 - 25

25 - 50

Greater than 50

6.Which therapies are you currently using for your acne? (Choose all that apply)

Accutane

Hormonal therapies (such as oral contraceptives)

Oral medications (such as antibiotics)

Topical treatments (such as gels, lotions, or creams)

Other (please specify)

7.Are you otherwise in good general health?

Yes

No (Please list medical conditions):

Thank you for completing the survey. We will review your information and contact you soon if you pre-qualify. Call (858) 571-6800 for further information.

9025 Balboa Avenue Suite 105

San Diego, CA 92123

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