|
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
*Would
you like us to call you? (strictly confidential)
Yes
No
*Would
you like a free brochure mailed to you?
Yes
No
|
* 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. |
