Chronic Hands Eczema and Healthy Volunteers - 5024

Thank you for showing interest in our clinical trial and helping to get new treatments into the hands of patients like you! You will find a short summary of the study below, along with a quick questionnaire to complete to help us connect with you.

Research on: Chronic Hands Eczema and Healthy Volunteers
Age: 18 to 65 years old
Compensation: Up to $615
Procedures to remember: Scans, Tape strippings, photography and blood draws
Number of visits: 6 visits over 17 weeks

If you would like to obtain more information regarding clinical research, feel free to email us at [email protected], call us at 514-521-3111 or text us at 438-806-0080.

Important: Must be 18 years or older to complete the form. A parent or legal representative must complete the form on the behalf of a minor.

Montreal subscription form

1. Where did you hear about this study?*
- Facebook
- Instagram
- Google
- STM – Poster
- STM – Electronic screen
- STM – Bus
- Newspaper – 24 hrs
- Radio – The Beat (92.5)
- Radio – 98.5
- Radio – Rythme FM (105.7)
- Radio – CKOI (96.9)
- Radio – NRJ (94.3)
- Radio – CJAD
- Radio – Rouge FM (107.3
- Radio – CHOM (97.7)
- Radio-Circulation (730 AM)
- Letter sent to your physician
- Dermatology Clinic / Patient card
- TV
- Other
2. Which dermatological condition do you suffer from?*
- Eczema (Atopic Dermatitis)
- Hand Eczema
- Hives (Urticaria)
- Psoriasis
- Palmoplantar Psoriasis
- Pustular Psoriasis
- Non-Pustular Palmoplantar Psoriasis
- Genital Psoriasis
- Hidradenitis Suppurativa
- Discoid Lupus Erythematosus
- Alopecia Areata
- Rosacea
- Papulopustular rosacea
- Notalgia Paresthetica
- Acne
- Vitiligo
- Hyperhidrosis
- Pattern Hair Loss (Androgenic/Androgenetic Alopecia)
- None (healthy volunteer)
3. Full name of the person completing the form:*
First Last
4. Month and Year of birth of the person completing the form: (MM/YYYY)*
5. Phone number to contact:*
Other number:
6. Email:*
7. What is the best time to reach you? Weekdays (Monday – Friday):
- Morning: 9am – 12pm
- Afternoon: 12pm – 5pm
- Evening: 5pm-7pm
8. Which city do you live in?*
Consent form: I confirm I am 18 years or older and allow the research clinic to contact me (by phone, by text messaging or by email) regarding this study.*
- Yes
- No
By submitting this form, I understand that the research clinic respects my privacy and will not share this information with third parties. I consent that Innovaderm Research Inc. retains the personal information Generic subscription form V2 28 FEB 2023 I have given in this form, for an undetermined period, for the purpose of contacting me in relation to any future studies.*
- I agree
- I don’t agree
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CRO Services
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Careers
Contact
FR

Dermatology Clinic
3530 Saint-Laurent boulevard
Suite 400
Montreal, QC, H2X 2V1, Canada

514-521-3111

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