Personalized Clinical Trial Request

First Name*

Last Name*

E-Mail*

Phone Number*

Full Company Address

Country
—Please choose an option—AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArctic OceanArubaAshmore and Cartier IslandsAtlantic OceanAustraliaAustriaAzerbaijanBahamasBahrainBaker IslandBangladeshBarbadosBassas da IndiaBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandClipperton IslandCocos IslandsColombiaComorosCook IslandsCoral Sea IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDemocratic Republic of the CongoDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaEuropa IslandFalkland Islands (Islas Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern and Antarctic LandsGabonGambiaGaza StripGeorgiaGermanyGhanaGibraltarGlorioso IslandsGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHowland IslandHungaryIcelandIndiaIndian OceanIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJan MayenJapanJarvis IslandJerseyJohnston AtollJordanJuan de Nova IslandKazakhstanKenyaKingman ReefKiribatiKerguelen ArchipelagoKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMidway IslandsMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNavassa IslandNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth SeaNorthern Mariana IslandsNorwayOmanPacific OceanPakistanPalauPalmyra AtollPanamaPapua New GuineaParacel IslandsParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRepublic of the CongoRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSpainSpratly IslandsSri LankaSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTromelin IslandTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUSAUruguayUzbekistanVanuatuVenezuelaViet NamVirgin IslandsWake IslandWallis and FutunaWest BankWestern SaharaYemenYugoslaviaZambiaZimbabwe

 

 

Please Provide A Sample Description to Be Used For Report(s)

Include an identifying number like study#, formula# etc

Sample Description*

SPF Testing Requirements

Select all that apply

FDA
FDA- FDA -Water Resistant 40 Minute- FDA - Water Resistant 80 Minute- FDA - Static

AS/NZ Australian/ New Zealand
AS/NZ Australian/ New Zealand- AS/NZ- Static- AS/NZ- Water Resistant

SPF ISO 24444 International Standard
SPF ISO 24444 International Standard- ISO 24444 Static

COLIPA European / Global Harmonization / Inernational
COLIPA European / Global Harmonization / Inernational- COLIPA - Static- COLIPA - Water Resistant- COLIPA - Very Water Resistant

Panel Size
1 Subject2 Subjects3 Subjects5 Subjects10 Subjects20 Subjects

 

In-Vitro UVA Testing Requirements

Select all that apply

FDA Critical WavelengthCOLIPA European / InternationalBoots Star Rating SystemUVA ISO 24443 International StandardAS/NZ Australian / New Zealand

 

Infrared Testing Testing Requirements

Select all that apply

In-vitro IRPFIn-vivo IR

Number of Subject Required in Panel

 

Safety Testing Requirements

Select all that apply

HRIPT24 Hour Patch48 Hour Patch

Number of Subject Required in Panel
50100200
Cumulative Patch
Number of Subject Required in Panel -20
Photo Toxicity
Number of Subject Required in Panel -20
Comedogenicity
Number of Subject Required in Panel -6
PhotoAllergy Maximization
Number of Subject Required in Panel -25

 

For any testing you selected so far, please complete the appropriate field below

Patch Configuration
OccludedSemi-OccludedOpen

Dilution
Undiluted, or...

Distilled Water?
Distilled WaterOther

Signature
DermatologistPediatricianGynecologistPlastic Surgeon

Eye Sting Assay
Eye Sting Assay
Number of Subject Required in Panel -5 Subjects10 Subjects

Facial Sting Assay
Facial Sting Assay
Number of Subject Required in Panel -5 Subjects10 Subjects

Vaginal Irritation
Vaginal Irritation
Number of Subject Required in Panel -5 Subjects10 Subjects

Ophthalmology
Ophthalmology
Number of Subject Required in Panel -30 Subjects60 Subjects

 

Efficacy Testing

Skin Surface Hydration via CorneometerSurface Evaluation of Living Skin (SELS) via VisioscanTransepidermal Moisture Loss (TEML) via DermaLab EvaporimeterSkin Lightening via ChromameterPhotoGrammetrix Analysis, PhGx®

Skin Moisturization - Electroconductivity via NovameterSkin Elasticity and Firmness via CutometerSkin Sebum via SebumeterMatched Scientific Photography, MSP™Subjective Questionnaire addressing user perceived benefits

For the testing requested above please fill out the applicable fields listed below:

- -

 

Deo Testing

Antiperspirant TestingDeodorant Testing

Time Points -1 Hour24 Hours48 Hours72 HoursOther Hours
Gender -MaleFemale

Submitted By / Authorised Signature

Date