1) Customer Information

Name

Address

City

State

Zip Code

Phone

Email Address

Requirement: Upon submitting survey provide a message stating that either A or B is required if you want to be eligible for free products

2) What dermatologic conditions do you suffer from? (Required)

Itching  Blemishes / Dark Spots  Dandruff / Flaking  Acne  Hair Loss / Hair Breakage  Razor Bumps  Scalp irritation / infection  None

3) How many of your household members suffer from any of the above dermatologic ailments?
(ex. dandruff, itching, razor bumps, acne, blemishes) (Required)

None  1  2  3 or more

 

4) How often do you visit you stylist / barber? (Required)

Once a week   Every 2 months   Once every 2 weeks   Every 3 months or more   Once every 3 weeks   I style / cut my own hair   Once a month

5) Who washes your hair? (Required)

Myself  My barber / stylist  A friend / family member

6) How much do you spend on personal skin and hair care products (non-cosmetic) a month?  (Required)

$20 or less  $41 – 60  $81- 100  $21 – 40   $61 – 80  $101 or more

7) How frequently do you shampoo your hair? (Required)

Daily (or almost everyday)   Every other day (3 – 4 times a week)   Twice a week   Once a week or less

8) How did you learn about Dr. Earles Products? (Required)

Dr. Earles Office   Salon / Barber Shop   TV commercial   Radio   Magazine / Newspaper Advertisement   Internet / Website   Friend, Family Member or  Co – worker

9) Have you ever used Dr. Earles’ Hair, Skin and Scalp products before? (Required)

Yes  No    * If answered “No” please skip to question #13

 

10) Which Dr. Earles products did you use?

Hair and Scalp Treatment (Original)   Hair and Scalp Treatment Lotion   Revitalizing Shampoo   Exfoliating Acne Peel   Cleansing Wash   Hydrating Cream   Razor Bump Treatment

11) Typically, how long did your Dr. Earles Products last you?

1 month or less    2 months     3 months or more

12) Do you find our products appearance?  (Select all that apply)

Attractive  Exciting  Professional  Not Attractive  Boring  Amateur

13) Do you find our website? (Select all that apply)

Attractive   Not Attractive   Exciting   Boring   Professional   Amateur   Easy to use   Complicated   Confusing

14) How old are you?

14 or under  15 - 19  20 - 29  30 - 39  40 - 49  50 - 59  60 and older

15) Any other comments /questions / suggestions about our customer service or products?