FACE Study Interest Form

Thank you for your interest in the FACE study!

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* 1. Full Name

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* 2. Email Address

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* 3. Phone Number

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* 4. Who is the participant with eczema?

Myself

My child

Other (please specify)

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* 5. What is the participants date of birth?

Date / Time

Date

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* 6. Does the participant have eczema affecting the Head and/or Neck?

Yes

No

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* 7. Is the participant currently on systemic treatment (medicines taken by mouth or by injection to treat their eczema such as methotrexate or dupilumab)

Yes

No

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* 8. If yes, specify what systemic treatment the participant is on

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* 9. Please upload photos of the participants eczema that affects their head, neck or face. The photos will be very helpful to allow us to assess the extent and severity of their eczema. All photos will be stored anonymously and securely.