Study Registration

THE TESTING CENTER

Age: *

Do you currently use a Hair Growth product? *

YES

HOW did you first notice your hair loss? *

What would regrowing the hair you've lost - mean to you?. Please give explain YOUR reason. *

Email: *

Phone

Looking at the above - Which looks MOST like YOUR hair loss/thinning hair? *

I-1

I-2

I-3

I-4

II-1 to II-2

What Hair Growth treatment have you used before?

Anthralin

Finasteride

Minoxidil

DHT Blockers

None

Dont Know

When did you first start to experience your thinning/loss of your hair? *

within the past year

Within the past 2 years

Within the past 3 years

Within the past 5 years

More than 5 years ago

What is your hair type?

Fine

Medium

Coarse

Thank you for your interest in this free to you program. After we review your questionnaire a Coordinator will reach out within the next 5 to 7 days to discuss potential next steps.

Do you have noticeable hair thinning?

YES

Do you have noticeable hair loss?

YES

Over the next 180 days do you plan on being away from home more than 2 weeks at a time? *

YES

Do you have High Blood pressure? *

YES

Where do you live? Lake Havasu City or Orange County CA? *

Orange County CA

Lake Havasu City AZ

Please list any Hair Growth products you have used or are currently using.

What best describes your hair oiliness? *

Oily

Medium

Dry

What is your TOP Goal? *

Regrow my Hair

Maintain my Current Hair

Prevent Hair Loss

Do you have a family history of thinning hair or hair loss?

YES

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Questions
Questions 2
Question 3

Name: *

What Demographic are you?

African American

Asian

Caucasian

Hispanic

Other

If you do have High blood pressure do you take medication for it?

YES

All testing by the Testing Center is Free. The Testing Center only tests products, WE DO NOT SELL them. Participants will never be asked to buy anything. Any product needed for the study will be supplied by the Testing Center. All results are based on the merits of the product/program being tested.

Please Answer the Questions BELOW to Register and see if you Qualify

for our upcoming Hair Growth Study!

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