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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
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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?
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
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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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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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