All information that you provide is strictly
confidential and used only for the purposes of
laser hair removal assessment. We never share your
information.
Fields with a * are required. When you have completed
the form, click the SUBMIT button.
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*Which
body area(s) are you considering for laser hair removal?
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What hair removal methods
have you previously used? Check all that apply.
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What color is the hair
in the area you want treated?
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What color is your
skin in the area you want treated?
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*What is your skin
type in the area you want treated?
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Type 1 - Always burn, never tan; very fair
skin, blond hair, blue or green eyes
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Type II - Usually burn; fair skin, light brown
to brown hair, blue or green eyes
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Type III - Sometimes burn; medium skin, brown
hair, brown or green eyes
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Type IV - Rarely burn; olive skin, brown or
black hair, dark brown or black eyes
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Type V - Tan well; dark brown skin, black hair,
black eyes
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Type VI - Tan deeply, never burn; black skin,
black hair, black eyes
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Do you have a sun tan?
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Have you been on Accutane
in the past 6 months?
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Are you on any medication?
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If yes, does it cause
photosensitivity?
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What is the name of
the medication?
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*Name:
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*Email address:
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*Phone Number:
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Any questions you have:
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