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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 |
* 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:
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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
(Outside U.S. Only)
* Zip Code/ Postal
Code
* Country
* Phone Number
* Would you like us
to call you? (strictly confidential)
Yes
No
* Would you like a
free brochure mailed to you?
Yes
No |
* 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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Required fields are marked with an
*. Make sure that
all the required fields are filled out. Thank you.
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We will
respond to your request via e-mail.
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