<%@ Page Language="VB" Debug="true" %> Permanent Hair Removal, Laser Hair Removal Clinics -- HairRemoval.com

Laser Hair Removal Consultation

Internet Search

Free and Confidential Laser Hair Removal Consultation

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 apply (hold the ctrl key to select multiple options).

Nothing Waxing Tweezing Shaving Nair, Epilstop Bleaching

3. What color is your hair in the area you want to be treated? Black Brown Blonde Grey White Light Brown Light Blonde Red

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 type in the area you are considering to have laser hair removal?
Type I - Always burn, never tan (extremely fair skin/blonde 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)

7. Have you been on Accutane in the past 6 months? No Yes

8. Are you currently on any medication? No Yes

If yes, is it photosensitive? Not Sure No Yes

What is the name of the medication?

Any other questions or concerns you would like to ask.

Personal information. Please fill in the appropriate information for better service. All Information is Strictly Confidential!
Name:
Address:
City:
State:	(choose one) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Provence/Region (outside US only)
Zip Code:
Phone:

Would you like us to call you? (strictly confidential) Yes No

Would you like a free brochure mailed to you? Yes No

The email address you would like any replies to this form to be sent to.