Stephens Research Study Participation Interest Form

A few requirements for the study include:
-Males and Females, ages 18-65
-Scars that are 1-3 months old and 1-5 inches long
-No keloid scars
-50% will have self-perceived sensitive skin
-Must avoid application of any topical products to your scar for at least 2 days prior to visit 1

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
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* 4. Email Address

* 5. Phone Number

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

* 7. Do you have self-perceived sensitive skin?

* 8.  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.

* 9. How did you hear about this study?

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