|
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. |
