Volunteer Form
Name
*
First Name
Last Name
Birthday
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Method
*
Email
Phone
Text
Race
*
White
Hispanic
Black
Other
Gender
*
Female
Male
Eye Color
*
Please Select
Brown
Blue
Green
Hazel
Other
Hair Color
*
Please Select
Black
Brown
Blond
Red
Gray/White
Other
Have you previously participated in a study with Dermico or KGL?
*
Yes
No
Are you currently on a GLP-1?
*
Yes
No
I have/had one or more of the following conditions
*
Facial freckles, age spots, or uneven pigment
Crow's feet lines
Undereye lines
Facial wrinkles
Acne
Rosacea
Psoriasis
Dry or sensitive skin
Eczema, atopic dermatitis, or allergies
My complexion is (choose one)
*
Fair - always burns, never tans (Caucasian)
Fair - burns easily, barely tans (Caucasian)
Medium - can burn, tans well (Caucasian)
Medium - seldom burns, tans very well (Mediterranean, Hispanic)
Dark - rarely burns, tans easily (Asian, Native American, African American)
Dark - rarely burns, deeply pigmented (African American)
Message
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