| Please fill in all the information below. 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
|
* 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. |
