Registry Home Registry Your Name Your Email Phone Address Suburb Postcode State VICTASSAWANTQLDACTNSW Gender MALEFEMALE Date of birth Do you have a form of Alopecia YESNO If so, which type Alopecia AreataAlopecia TotalisAlopecia UniversalisAndrogeneticCicatricial AlopeciaPerinaevoid Alopecia AreataAlopecia Areata BarbaeOther Does any member of your family have Alopecia NOSiblingCousinParentGrandparentAunt/UncleChildSelf Can your image be used in marketing YESNO Do you want to be contacted regarding research trials for your category YESNO Do you want to be notified of upcoming events YESNO Would you like to be contacted regarding volunteer assistance needed at events YESNO Please provide a brief description in what area you would like to help How did you find out about AAAF Dr / DermatologistInternetEventFriend / ReferralAdvertisingOther I have read Privacy Policy and Publishing Personal Information and agree to be added to the Registry. Please prove you are human
