|
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)
|
* 7.
Have you been on Accutane in the past 6 months?
Yes
No
|
|
* 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!
*
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. |
