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.
Laser Hair Removal Consultation |
