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All fields are optional.

Name:

Email Address:

Address:

City:

State:

Phone Number:

Length of Illness:
(ex: 5 yrs)

Symptoms: Lesions or sores
Fibers or filaments on skin
Itching
Stinging
Hair Loss

Diagnosis by a physician:
(ex: eczema, psoriasis, psychiatric diagnosis)

Additional symptoms or comments:

Name:
Email Address:
Address:
City:
State:
Phone Number:
Length of Illness: (ex: 5 yrs)
Symptoms:	Lesions or sores Fibers or filaments on skin Itching Stinging Hair Loss
Diagnosis by a physician: (ex: eczema, psoriasis, psychiatric diagnosis)
Additional symptoms or comments: