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• Did you use Dupixent?*
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• Are you willing to share medical records as proof?*
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• Diagnosis or first biopsy 3–12 months after using Dupixent?*
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• Do you have a history of any of the following conditions?*
  Select OneEpstein–Barr Virus (EBV)MononucleosisMonoHIV or AIDSPrior chemotherapy treatmentOrgan transplantImmune-suppressing meds used >6 months before first Dupixent doseReceived a COVID-19 vaccine within 30 days before CTCL diagnosisNo history of any of these conditions
• Were you diagnosed with cutaneous T-cell lymphoma (CTCL) after starting Dupixent?*
  Select OneMycosis fungoidesSézary syndromeOther
• Has CTCL been confirmed by a skin biopsy and pathology report?*
  Select OneYesNo biopsy confirmationSelf-suspected only

• Are you currently working with an attorney?*
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