Laser15.com - ENDERMOLOGIE

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ONLINE ANALYSIS & PROMOTIONS

Please fill out our questionnaire to determine if you're a good candidate for laser hair removal.

In order for us to best assist you, we ask that you complete the entire questionaire.


To confirm you are a candidate for laser hair removal, please fill out the form and answer the following questions:
Name:
Address:
Phone Number:
City:
State:
Zip Code:
E-Mail:
What body parts are you considering for laser hair removal? Face Underarms Back Bikini Legs Other
Have you previously underwent the laser hair removal procedure? Yes No
What is the color of your hair on the areas to be treated?: Black Brown Blonde White Other
Is your skin color one of the following? White Brown Tan Black Other
Is your skin type one of the following? Type I/II always burn, never tan (extremely fair skin) Type III/IV sometimes mild burn, tan about average (medium colored skin) Type V moderately pigmented, tan more than average (olive skin, brown skin) Type VI deeply pigmented, never burns (black skin)
Have you been on Accutane in the past six months? Yes No
Are you currently on any medications? Yes No
If yes, is it photosensitive? Yes No
What what is the name of the medication(s)?

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