The code block below illustrates how one might use # and // as comments in your logic and calculations.

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SECURE-Psoriasis Registry

Surveillance Epidemiology of Coronavirus (COVID-19) Under Research Exclusion (SECURE)

This form is to be completed by a health care professional caring for a patient with psoriasis and documented coronavirus (COVID-19). Please report only confirmed COVID-19 cases, and report after a minimum of 7 days or after sufficient time has passed to observe the disease course through resolution of acute illness or death.

If you have any questions, please reach out to COVID_PSO@wakehealth.edu

Thank you!

Name of reporter

Email address of reporter

Name of physician providing care for psoriasis

Name of center/practice providing care for psoriasis

Age

Country of residence

State of residence

Gender

Female

Male

Other

SECURE-Psoriasis Registry

You have selected an option that triggers this survey to end right now.