Stephens Research Study Participation Interest Form

A few requirements for the study include:
- Males and females
-12-22 years of age
-Mild to Moderate facial acne

Please note:
*All information you provide will be kept confidential
*You may be contacted by telephone
*Your information may be added to a database

* 1. First Name

* 2. Last Name

* 3. Date of Birth

Date / Time

* 4. Email Address

* 5. Phone Number

* 6. If we call, what is the best time to reach you?

* 7.  Have you participated on a study at Stephens before?  Your response to this question is not dependent upon your eligibility. It helps give us information on how many new participants we have.

* 8. How did you hear about this study?