What body area are you considering for laser hair removal?

What have you previously used to remove your unwanted hair? Please check all that apply

Nothing
Waxing
Tweezing
Shaving
Nair, Epilstop
Bleaching

if you checked Waxing, Tweezing, Bleaching or Nair/Depilatories above, have you Waxed, Tweezed, Bleached or used Nair/Depilatories within the last six weeks? 

N/A
Yes
No

What color is your hair in the area you want to be treated?

- Select - Black Blonde Brown Gray White Light Brown Light Blonde Red

What color is your skin in the area you want to be treated?

White
Brown
Black
Light Brown

Do you have a sun tan?

Tan
Slight Tan
No Tan

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/blonde 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)

Have you been on Accutane in the past 6 months?

Yes
No

Are you currently on any medication?

Yes
No

If yes, is it photosensitive?

N/A
Not Sure
Yes
No

What is the name of the medication?

Any other questions or concerns you would like to ask.

Would you like us to call you? (Strictly Confidential) Yes No

Would you like a free brochure mailed to you? Yes No