Observational Research Study Survey

Therapeutics Clinical Research is conducting a clinical research study for a study involving patient comfortability with a topical patch. 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 18 years of age or older?

Yes

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

Yes

N/A; I am male

4.Have you been diagnosed with a topical skin disease?

Yes (Please list skin disease):

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,

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