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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.
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*
3. What color is
your hair in the area you want
to be treated?
Brown
Black
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 |
*
5. Do you have a
sun tan?
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
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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
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. E-mail
address:
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. |
|
We will respond to your request
via e-mail |
