Laser Hair Removal
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Complete the following questionnaire to find out if you are a good candidate for Laser Hair Removal treatment.

ALL INFORMATION IS STRICTLY CONFIDENTIAL. We Never Sell Your Name or Email Address. We Value Your Trust In Us. Thank You!

Required fields are marked with an *.

* 1. What body area are you considering for laser hair removal?


* 2. What have you previously used to remove your unwanted hair? Please select all that
Nothing Tweezing Nair Treading
Waxing / Sugaring Shaving Epilstop Electrolysis
* 3. What color is your hair in the area you want to be treated?

Light Brown
Light Blonde
* 4. What color is your skin in the area you want to be treated?

Light Brown
* 5. Do you have a sun tan?

Slight Tan
No Tan
* 6. What is your skin (Fitzpatrick) type in the area you are considering to have laser
hair removal?

Type I - very fair, "transparent" - Always burn, never tan (blond hair, blue or green eyes)
Type II - fair skin - Usually burn, tan less than about average (sandy brown to brown hair, green/blue eyes)
Type III - fair to light olive - Sometimes mild burn, tan about average (brown hair, green/brown eyes)
Type IV - olive to brown - Rarely burn, tan more than average (brown/black hair, dark brown/black eyes)
Type V - dark brown - Moderately pigmented, tans profusely (black hair, black eyes)
Type VI - black skin - Deeply pigmented, never burns (black hair, black eyes)
* 7. Have you been on Accutane in the past 6 months?

Yes No
* 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:


* 9.) Personal information. Please fill in the appropriate information for better service.
 All Information is Strictly Confidential!
* Name

* City
* State

 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
* 10. E-mail address: E-mail must be provided to receive information!



Required fields are marked with an *.  Make sure that all the required fields are filled out. Thank you.

We will respond to your request via e-mail