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Participants needed in the Los Angeles area for a clinical study on a natural hair loss treatment

How it works

You complete the application form below and if selected you will be eligible to participate in the clinical study. Participants will receive free supplies of the product.

Application form

Age:

Sex:

Male

Female

How long have you suffered from hair loss?

years

How severe is your hair loss?

If unsure please see the following charts

Diagnosed Cause of Hair Loss

List any medication you are currently using or have during the past 6 months

What hair loss products have you used during the past 6 months?

What hair loss products are you currently using?

Name:

Address:

State/Province:

Zip/Postal Code:

Home Phone:

Work Phone:

Email address:

Inclusion in the study is not guaranteed by completing this form.
You will be contacted if you were selected.
If you were not selected your information will not be disclosed to any other party
besides those involved with this study.