Dermatology Contact Survey
RequiredRequired Question(s)
Thank you for actually reaching this survey. That was the hard part. Now for the easy stuff.
 
Required
The PERSONAL INFORMATION requested below is YOUR name, YOUR email address and YOUR general location (no street address or postal code). This is NOT where you provide contact information for your dermatologist.

This personal information will NEVER be shared with third-parties, e.g., healthcare professionals, PRP researchers, pharmaceutical companies, etc. I use it to document the PRP patients and caregivers sharing the names of PRP-savvy dermatologists.


First Name:
Last Name:
Email Address:
emailaddress@xyz.com
State/Province
(US/Canada):
Country:


Please identify your primary dermatologist and his/her contact information. This should be the PRP-savvy dermatologist to whom you would refer a newly diagnosed PRP patient or caregiver. 


If, however, your dermatologist has NOT demonstrated the qualities of PRP savviness, ONLY enter N/A


EXAMPLE:

Dr. Arturo Dominguez
University of Texas Southwestern Medical Center
5939 Harry Hines Boulevard, 4th Floor, Suite 100

Dallas, TX 75390

 

 

350 characters left.


Feel free to support your dermatologist's PRP savviness with additional comments,

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350 characters left.