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First Name *

Last Name *

Email *

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Age *

How did you indentify at birth?FemaleMale

Postal/Zip *

Please select your ethnicity below . . . *AboriginalBlack / African AmericanNorth American/White EnglishScottish French IrishGerman Italian Ukrainian DutchPolishPortugueseWelsh Norwegian Swedish Hungarian Russian East Indian Chinese Filipino Mexican Spanish Cuban Austrialian Japanese Korean South Asian Arab / West Asian Southeast Asian West Asian Arab

How would you best describe your own skin? *Dry Normal Oily Combination I don't know

Check each that applies to you. *

• I prefer a "Dewy Look"
• I prefer a "Matte Look"
• I like the feel of oils on my skin
• I stick to a skin care regime
• I am kinda lazy when it comes to skin care

• YES I have been prescribed topical Vitamin A (eg. Tezorac / Retin A / Tretinoin).
• YES I have been prescribed & used oral Vitamin A (eg. Accutane).

If you replied "YES" to being prescribed Vitamin A - What percentage and brand?

What best describes your skin color? * *Light / Pale White White / Fair Medium White to Light Brown Olive / Moderate Brown Brown / Dark BrownVery Dark Brown to Black

• I am typically outside in the sun a lot.

What were your past suntanning habits? *Never Tanned Tanned a Little Tanned Average Tanned OftenExtra Crispy

What are your current suntanning habits? * *Never Tan Tan a Little Tan Average Tan OftenExtra Crispy

• I have had skin cancer.
• YES skin cancer runs in my family.
• YES I am prone to acne.
• YES I am prone to Hyper-pigmentation (Liver Spots/Brown Spots/Sun Spots).
• YES I am prone to Congested Skin (i.e.: blackheads).

What really bothers you about your skin the most and therefore, what are you ultimate goals? *

Are you currently on birth control? *NoYes. Birth Control Pill Yes. Traditional IUDYes. Cooper IUDYes. Birth Control Patch Yes. Birth Control Shot Yes. Birth Control Implant

Are you are allergic to ANYTHING (even if it does not apply to your skin)? *

• YES I am allergic to Aspirin.

Why now? Is there a particular event or chapter in your life that has made you want to learn the truth about skin care? *

How did you hear about [ jodiLee labs ]? *

• Talked to a [ jodiLee labs ] team member.
• Referred by a [ jodiLee labs ] client.
• Seen you on Instagram.
• Seen you on Twitter.
• Found you during a Google search.
• Seen your Telegram channel.
• Other

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