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Please provide the following cantact information:
* Name	First: Last:
* Phone Number
* E-mail
Would you like us to call you?
Yes No
What body area are you considering for laser hair removal?

What have you previously used to remove your unwanted hair?
Nothing Shaving Waxing Tweezing Epilstop,Nair
What color is the hair in the area that you want to be treated?
Black Brown Red Blonde Grey
What color is the skin in the area you want to be treated?
White Light brown Brown
Do you have a suntan?
Yes No
What is your skin type in the area you are considering to have laser removal?
Type 1 - Burn always Type 2 - Burn sometimes Type 3 - Seldom burn Type 4 - Moderately pigmented, tans profusely Type 5 - Moderately pigmented, tans profusely Type 6 - Deeply pigmented, never burn
Have you been on Acutane in the past 6 months?
Yes No
Are you currently on any medication?
Yes No
If .Yes. What is the name of the medication?

Is it photosensitive?
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ADD:481 8th Ave - Suite 815 New York, NY 10001
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