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Get started today with the Laser Hair Removal process...
you can be hair free sooner than you think!

Complete the following questionnaire to find out if you are a candidate for Laser Hair Removal.

ALL INFORMATION IS STRICTLY CONFIDENTIAL.
We Never Sell Your Name or Email Address. We Value Your Trust In Us. Thank You!


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!

* 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.

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