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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 (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, does it cause
photosensitivity?
Yes
No
Not Sure
What is the name of the medication?
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
*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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Required fields are marked with an
*. Make sure that all the
required fields are filled out. Thank
you.
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We will respond to your request via
e-mail. |
