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Required
fields are marked with an
*.
*
1. What body area are you considering for
laser hair removal?
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*
2. What have you previously used to remove
your unwanted hair? Please select all
that apply (hold the ctrl key to select
multiple options).
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*
3. What color is your hair in the area you
want to be treated?
Black
Brown
Blonde
Grey
White
Light Brown
Light Blonde
Red
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*
4. What color is your skin in the area you
want to be treated?
White
Brown
Black
Light Brown
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*
5. Do you have a sun tan?
Tan
Slight Tan
No Tan
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*
6. What is your skin type in the area you
are considering to have laser hair removal?
Type I- Always burn, never tan (extremely fair
skin/blond hair/blue/green eyes)
Type II- Usually burn, tan less than about
average (fair skin, sandy brown to brown
hair, green/blue eyes)
Type III- Sometimes mild burn, tan about
average (medium skin, brown hair,
green/brown eyes)
Type IV- Rarely burn, tan more than average
(olive skin, brown/black hair, dark
brown/black eyes)
Type V- Moderately pigmented, tans profusely
(dark brown skin, black hair, black eyes)
Type VI-Deeply pigmented, never burns (black
skin, black hair, black eyes)
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*
7. Have you been on Accutane in the past 6
months?
Yes
No
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*
8. Are you currently on any medication?
Yes
No
If yes, does it cause photosensitivity?
Yes
No
Not Sure
What is the name of the medication?
Any other
questions you would like answered:
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*
9.) Personal information. Please fill in the
appropriate information for better service.
All Information is Strictly Confidential!
*
Name
*
Address
*
City
*
State
*
Province / Region (Outside U.S. Only)
*
Zip Code/ Postal Code
*
Country
*
Phone Number
*
Would you like us to call you? (strictly
confidential)
Yes
No
*
Would you like a free brochure mailed to
you?
Yes
No
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*
10. What e-mail address would you like the
analysis results sent to? E-mail must be
provided to receive information!
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Required fields are marked with an
*.
Make sure that all the required fields are
filled out. Thank you.
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We will respond to your request via e-mail. |
