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? (If you are not on medication, please enter N/A)
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)
Zip Code/ Postal Code
Country
* Phone Number
(Please enter only numbers, no spaces)
* 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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Complete this questionnaire and receive a free complexion analysis valued at $105. |
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