In order to be considered for participation in the hair loss trial, please complete the following form that will be evaluated by our group of experts

All selected participants will be provided with a 6-month supply of a supplement (free of charge) from a world-renowned brand that is proven to normalise the Hair Growth Cycle.

Please fill in the form below (estimated time 2-3 minutes)

Important note – your personal data will be kept completely confidential and will not be distributed to third parties

About you

*Given Name(s)

*Surname

*Country

**Email

*Sex

*Age

*State

* Required fields
** A requirement for inclusion in the trial, is that you register with a personal email and that you review it daily, otherwise it will not be possible to confirm future steps of the trial should you be selected.

Your hair history

*Question 1 of 9

Are you currently experiencing any symptoms of hair thinning and/or hair loss?

*Question 2 of 9

Have you been diagnosed with any specific hair loss condition(s)?

If ”yes” please name the diagnosis and/or give a short description.

*Question 3 of 9

How long have you experienced this hair growth issue?

*Question 4 of 9

Have you tried other treatments for your hair growth issue?

If "yes" briefly describe which drugs, supplements, liquid treatments etc.

*Question 5 of 9

Do you have any other chronic diseases or health issues that require drug treatment?

If "yes" briefly describe, which disease and what drugs

*Question 6 of 9

Have you recently been through a stressful period?

If "yes" briefly describe when and what - Medical treatment, family problems etc.

*Question 7 of 9

Are you currently pregnant?

*Question 8 of 9

Are you currently breast-feeding?

If "yes" please state in months for how long?

*Question 9 of 9

ALLERGY - IMPORTANT:
Are you allergic to fish or other seafood products?

PLEASE NOTE - Your personal data will be held totally confidential and will not be distributed to third parties.

Terms and Conditions

a. By clicking ‘SUBMIT ANSWERS’ I accept that if I am invited to take part in the trial that I am also giving consent for the results of the trial to be used anonymously in marketing activities. (Note: no names or personal details will be used.)

b. By clicking ‘SUBMIT ANSWERS’ I accept that I may receive emails from time to time from the organisers of this Hair Loss Trial.