MKTP Consult Request

Please be advised that this information is only used to determine your possible candidacy for the MKTP. Once your form is processed someone from the MKTP Team will be in contact with you within 7 - 10 days.

*Asterisk indicates required field.

First Name Last Name Email Phone Number Address City State ZIP Code Date of Birth If you have vitiligo, when was the last time you had a new spot or had an old spot that grew? Where on your body do you have vitiligo or other loss of pigment? Do you have vitiligo on your fingertips, around the nailbeds or on your lips? When you scratch or otherwise injure your skin do you develop vitiligo or a thick scar in the area? Do you have any additional medical problems?

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