| 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. |
