Volunteers with acne are needed to participate in a clinical trial. This questionnaire form will take less than 5 minutes to complete.

Financial compensation will be provided upon your successful completion of the study.

All information given will be kept strictly confidential and is only used within the purposes of the clinical study. Contact Ann Lee, the Clinical Manager, at (347) 879-0333 or acnestudy2013@gmail.com if you have trouble completing the online form, or if you have any questions.

* 1. Full Name

* 2. Phone Number

* 3. Email Address

* 4. What is your occupation?

* 5. Age

* 6. Gender

* 7. Do you have acne?

* 8. Do you have any other systemic or dermatological condition other than acne?

* 9. How did you hear about this clinical study?

* 10. **URGENT - The first visit was this Friday, however there are a couple more spots open for this study. Please fill out the questionnaire ASAP, as I will be scheduling appointments for this upcoming Monday (February 4th), Tuesday (5th) or Wednesday (6th) depending on the doctor's schedule. Note that the other four followup visits will all take place on Friday.

Are you available for in-person appointments at the clinical site on ALL of the following Fridays: February 1st, March 1st, March 15th, March 29th and April 26th?

Each appointment will last for approximately 30 minutes. The clinical site is located on the Upper East Side.