Please fill in all the information below. 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 apply (hold the ctrl key to
select multiple options).
|
*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/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:
|
*9.) Personal information. Please
fill in the appropriate information for better
service. All Information is Strictly Confidential!
*First Name
*Last Name
*Address
*City
*State
*Province
/ Region (Outside U.S. Only)
*Zip
Code/ Postal Code
*Country
*Phone
Number
|
*10. What e-mail address would
you like the analysis results sent to? 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. |
