Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Gender
*
Female
Male
Non-Binary/Other
Age
*
Under 1
2-5
6-10
11-17
18-24
25-34
35-44
45-54
55-64
65-74
75+
Are you a caretaker of someone with eczema?
*
Yes- I will test products on my child
No- I will test products on myself
If you are a caretaker of someone with eczema, how old are they?
Under 1
2-5
6-10
11-17
18-24
25-34
35-44
45-54
55-64
65-74
75+
Skin Tone
*
1- Light Pale White
2- White, Fair
3- Medium, White to Olive
4- Olive, Moderate Brown
5- Brown, Dark Brown
6- Very Dark Brown, Brown to Black
Are you able to find products in the market that address your skin disorder?
*
Yes
No
Sometimes
How often do you treat your skin?
*
Less than Once Daily
Once Daily
Twice Daily
More than Twice Daily
What type of atopic skin issues do you experience? (Choose all that apply)
*
Do you/ have you used prescription medicine to treat these skin disorders?
*
Yes
No
Which prescription medicines have you tried? What did you like/dislike?
What is the most money you'd spend on a single product to address your skin disorder?
*
$12-19
$20-$29
$30-39
$40-49
$50-59
$60-69
$70+
Where is your go-to place to shop for skin care?
*
Amazon
Sephora
Ulta
Target
Department Store
Other Drugstore
Brand's Website (DTC)
Other
Where else do you shop for your skin care?
*
What are your preferred brands?
*
Other Preferred Sensitive Skin Brands
*
Do you prefer skin care with plant-based, organic, and/or natural ingredients?
*
Yes
No
Sometimes
Do you think FDA-approved actives address skin disorders more effectively?
*
Yes
No
Sometimes
Do you believe more expensive skin care products are more effective?
*
Yes
No
Not Sure
Which of the following skincare products do you include in your skin care routine?
*
Which of these steps is most important to you?
Cleanser
Exfoliator
Toner
Moisturizer
Serum
Mask/ Treatment
Eye Cream
Sunscreen
Which of the following would most compel you to purchase an eczema product?
TikTok Influencer Review
Amazon Reviews + Top Of Search
Recommended at Sephora or Ulta
Instagram Ad or Story
Facebook Groups
Word of Mouth
Do you have a dedicated night-time routine?
Yes
No
Which of the following lifestyle choices do you believe impact skin health?
Have you heard of the gut microbiome and/or the gut-brain-skin (GBS) connection?
*
Yes
No
Are you aware of a separate microbiome that surrounds your skin?
*
Yes
No
Which of the following products would you like to trial consistently for 4 weeks?
*
Participation requires your feedback three times. We send you a link to a brief survey on Day 1, Day 14, and Day 28. Each survey can be completed under 5 minutes.
*
Preferred Method of Communication
Where would you like the samples to be sent?
Please provide your mailing address.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country