Information Request Form

Registration Information

Title

First Name *

Last Name *

Email *

Address *

City *

State / Province

ZIP / Postal Code *

Country

Gender

Yes, I would like to receive e-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

What is your relationship to person with alopecia? *

Gender of person with alopecia *

Date of Birth (person with alopecia areata) *

Month

Day

Year

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?

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