| Personal Information |
| *Name : |
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| Gender : |
Male
Female |
| *Address : |
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| *City : |
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| *State : |
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| *Zip/Postal Code : |
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| Contact Information |
| *Phone : |
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| *Daytime Contact Number? |
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| *What day of the week is best for your appointment? |
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| *What time of day is best for you? |
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| *What e-mail address would you like the analysis results sent to? |
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| *What body area(s) are you considering for laser hair removal? |
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| What have you previously used to remove your unwanted hair? |
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| *What color is your hair in the area you want to be treated? |
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| *What color is your skin in the area you want to be treated? |
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| *What is your skin type in the area you are considering to have laser hair removal? |
| Please check all that apply |
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Type I |
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Always burn, never tan (extremely fair skin/blond hair/blue/green eyes) |
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Type II |
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Usually burn, tan less than about average (fair skin, sandy brown to brown hair, green/blue eyes) |
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Type III |
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Sometimes mild burn, tan about average (medium skin, brown hair, green/brown eyes) |
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Type IV |
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Rarely burn, tan more than average (olive skin, brown/black hair, dark brown/black eyes) |
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Type V |
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Moderately pigmented, tans profusely (dark brown skin, black hair, black eyes) |
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Type VI |
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Deeply pigmented, never burns (black skin, black hair, black eyes) |
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| Medical History |
| Have you been on Accutane in the past 6 months? |
Yes
No |
| Are you currently taking Bactrim? |
Yes
No |
| Are you currently on any medication? |
Yes
No |
| Is it photosensitive? |
Yes
No
Not Sure |
| What is the name of the medication? |
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| How did you hear about us? |
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| Please read our Cancellation Policy |
