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, is it photosensitive?
Yes
No
Not Sure
What is the name of the medication?
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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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We will respond to your request via e-mail
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