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Gaining Even More
(
order form)
1.
What is your name?
2.
What is your textable phone number?
3.
What is your email address (for your invoice and product information)?
4.
How did you hear about Gaining Even More (GEM)?
Word of Mouth
Dr. Staci Adams
Social Media
Other (please specify)
5.
Would you like to order GEM Deep Conditioning Packs?
Not at this time
Yes please, ONE for $30
Yes please, TWO for $50
Yes please, FOUR for $90
Other (please specify)
6.
Would you like to order GEM Nourishing Drops?
Not at this time
Yes please, 15 mL for $30
Yes please, 30 mL for $50
Yes please, 60 mL for $100
Yes please, 120 mL for $190
Yes, please 235 mL for $380
Other (please specify)
7.
Are you currently experiencing scalp issues?
Yes
No
If yes, please explain
8.
Briefly describe your hair goals.
9.
Are you TTC, pregnant, or nursing (answers alter ingredients in your personalized mix)
Yes, I am TTC / pregnant
Yes, I am nursing
No
Other (please specify)
10.
Are you interested in consultation services? If so, please explain
Not at this time
If YES, please explain
11.
Would you like to buy a T-shirt?
No, Thank you.
If YES, what size?
12.
To update your order with accurate shipping estimates, please provide a shipping address (no P.O. Boxes, please)
Please text, "
GEM ORDER SENT
" to confirm receipt of your order, to
(404) 791-4396
.
