Get started today with the Laser Hair Removal process...
you can be hair free sooner than you think!
Complete the following questionnaire to find out if you are a candidate for Laser Hair Removal.
ALL INFORMATION IS STRICTLY CONFIDENTIAL.
We Never Sell Your Name or Email Address. We Value Your Trust In Us. Thank You!
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.
* 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
Non US
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
D.C.
Puerto
Rico
Virgin Islands
Guam
* Province / Region (Outside
U.S. Only )
* Zip Code/ Postal Code
* Country
USA
Canada
Bahama Islands
United Kingdom
Other
* 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.