Nodular Basal Cell Carcinoma (Skin Cancer) Study Survey

Welcome to the Nodular Basal Cell Carcinoma Clinical Research Study

Thank you for your interest in this study. In order to determine if you pre-qualify for this research study, we will ask you a few questions about you and treatments you may have tried. You may stop answering at any time and do not need to answer any questions that make you feel uncomfortable. All information you provide will be kept conﬁdential and stored in the secured study database if you are enrolled in the study. If you do not qualify for the study, your information will also be kept in the secured database until the end of the study and then destroyed unless you elect to have us retain your information for potential future trials (see question 11 below).

1.Are you at least 18 years old?(Required.)

Yes

2.Please provide your contact information:(Required.)

Name

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

3.For the phone number you provided above please specify:(Required.)

Cell

Home

4.Are you male or female?(Required.)

Male

Female

5.Females only: Are you pregnant, lactating, or planning to become pregnant during the study?(Required.)

Yes

N/A, Male

6.Have you been clinically diagnosed by a healthcare professional with Nodular Basal Cell Carcinoma (nBCC) lesion (skin cancer) with a minimum diameter of 0.5 cm and with a maximum longest diameter of 1.3 cm?(Required.)

Yes

7.Was your nBCC biopsied previously?

N/A

Yes, (please specify date)

8.Have you used any medications or received any treatments/procedures for your nBCC?(Required.)

N/A

Yes, (please specify)

10.May we retain your information so we may contact you about potential future studies?(Required.)

Yes

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