Form
Name
First Name
Last Name
Phone Number for follow up
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you currently experiencing any of the following? Check all that apply.
Bloating
Digestive issues
Low energy/fatigue
Autoimmune disorders
Anxiety
Brain fog
Trouble sleeping
Headaches
PMS
Menopause
Other
Are you currently satisfied with your skin?
Yes
No
Meh, could be better
Are you experiencing any of these common skin issues? Check all that apply.
Acne
Oily skin
Dry skin
Signs of aging
Fine lines/wrinkles
Dark spots/Age spots
Dull skin/lacking glow
Eczema
Rosacea
Other
Are you familiar with ingredients in wellness and skincare products and how these things can affect your overall health?
I’m familiar but don’t really care
I’m somewhat familiar but could use some more info
I’m an avid label reader and all about that low-tox life
I’m not familiar with how ingredients affect my overall health
I want to help you thrive in 2025! What’s the best way I can share resources with you to address some of these things that might be affecting your skin or your overall health? Check all that apply.
Podcasts and book recommendations
Send me the deets on virtual wellness workshops to learn more
Product recommendations for skin or gut health
Invite me to local in-person workshops to learn more about creating sustainable healthy nutrition or skincare routines
All of the above
Can I add you to my private Facebook group where I share resources, health hacks, tips, product links, discount codes, workouts, healthy recipes, and virtual & in person connection opportunities for living your best life?
Yes
No thanks
Are you open to hopping on a quick 15 min consultation call to discuss your survey?
Yes
No
Are you on my email list? If you’d like you can be added, what’s your email?
example@example.com
Let’s connect on social! What’s your IG handle? I’m @janiegardner
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