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Therapeutics Clinical Research is conducting a clinical research study for a topical medication for people living with vitiligo. 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.

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* 1. Tell us about yourself:

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* 2. Are you 18 years of age or older?

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

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* 4. Have you been diagnosed with vitiligo?

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* 5. One of the primary qualifications for the study is that you have a certain percentage of your body affected with vitiligo. The way you can tell what your percentage might be is: 1% is equal to about the size of your open hand including the palms and fingers. If you were to use your hand to cover up all of the vitiligo on your body, how many hands do you think it would take?

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

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* 7. How did you hear about us?

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.

9025 Balboa Avenue Suite 105
San Diego, CA 92123
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