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)

About you

*Given Name(s)

*Surname

*Year of birth

*Sex

*Country

*State

*Mobile number

+65

**Email

* 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 11

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

*Question 2 of 11

How long have you experienced this hair growth issue?

*Question 3 of 11

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

*Question 4 of 11

Have you sought advice about your hair loss?

*Question 5 of 11

Have you tried other treatments for your hair growth issue?

*Question 6 of 11

Have you recently been through a stressful period?

*Question 7 of 11

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

*Question 8 of 11

To what extent are you interested in diet and exercise?

*Question 9 of 11

Are you currently pregnant?

*Question 10 of 11

Are you currently breast-feeding?

*Question 11 of 11

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