Information Request Form

Registration Information

Title

First Name *

Last Name *

Email *

Address *

City *

State / Province *

ZIP / Postal Code *

Country

Gender

Date of Birth (person with alopecia areata)

Month

Day

Year

Yes, I would like to receive e-mail from National Alopecia Areata Foundation

Yes

Yes, I would like to receive postal mail from National Alopecia Areata Foundation

Yes

Information about individual with Alopecia Areata

I have a family member with alopecia areata

Yes

I have alopecia areata

Yes

Relation

Gender of person with alopecia

Age

Has Alopecia Areata (patchy hair loss)?

Has Alopecia Totalis (Total scalp hair loss)?

Has Alopecia Universalis (total body hair loss)?

Would you like information on upcoming clinical trials?

Have you or your family member joined the The Alopecia Areata Registry, Biobank, and Clinical Trials Network?

Comments

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