Clone of UAT Recruitment Pre-Launch Interest Survey

1
lh_source
2
Do you wish to register your interest for the HALO Trial? If you register your interest, we will collect your name, email address and telephone number so that we can contact you to check your eligibility when the trial officially launches this summer.* This field is required.
YESNO
3
Do you agree to have the information you enter here stored by Lindus Health, following the terms of the Lindus Health and Nexalin privacy policy, and shared with the research team?* This field is required.Your agreement is required in order to move forward. If you have any questions, please email us at halo@lindushealth.com
YESNO
4
What is your name?* This field is required.
First Name
Last Name
5
What is your email address?* This field is required.We will only use this to contact you about the HALO Trial.
example@example.com
6
What is your mobile phone number? We will only use this to contact you about the HALO Trial.
Should be Empty: