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! |
| Please fill in all the information below. Required fields are marked with an *. |
| * 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. |
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| * 3.
What color is your hair in the area you want to be treated? |
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| * 4.
What color is your skin in the area you want to be treated? |
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| * 5.
Do you have a sun 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) |
| * 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? |
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| Any other questions you would like answered: |
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* 9.)
Personal information. Please fill in the appropriate information for better service.
All
Information is Strictly Confidential! |
| * Name |
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| *Address |
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| * City |
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| * State |
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| * Province / Region (Outside
U.S. Only) |
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| * Zip Code/ Postal Code |
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| * Country |
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| * Phone Number |
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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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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. |
