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| Age |
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Services you are interested in. |
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| 4. |
What body or face areas are you considering for laser hair removal? (Tip: hold ctrl key to choose more than one) |
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| Face: |
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Body: |
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What have you previously used to remove your unwanted hair? (Tip: hold ctrl key to choose more than one)
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What colour is your hair in the area you want to be treated? |
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What is the thickness of the hair in the area to be treated? |
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What colour is your skin in the area you want to be treated? |
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Do you have a tan? |
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What is your skin type in the area you are considering to have laser hair removal? |
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Type I- Always burn, never tan
(extremely fair skin/blond hair/blue/green eyes) |
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Type II- Usually burn, tan less than about average
(fair skin, sandy brown to brown hair, green/blue eyes) |
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Type III- Sometimes mild burn, tan about average
(medium skin, brown hair, green/brown eyes) |
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Type IV- Rarely burn, tan more than average
(olive skin, brown/black hair, dark brown/black eyes) |
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Type V- Moderately pigmented, tans profusely
(dark brown skin, black hair, black eyes) |
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Type VI-Deeply pigmented, never burns
(black skin, black hair, black eyes) |
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| 11. |
Are you pregnant? |
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Medical History
Please give details of any relevant Medical Issues you have had if any exist. |
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Are you presently on any medication? |
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Please specify details of medication? |
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Any questions you would like answered? |
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Personal information. Please fill in the appropriate information for better service. |
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| 14. |
Preferred consultation location:
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Where did you hear about us? If radio please specify
station? If print please specify publication? If
internet please specify search site used? |
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Please specify:
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Please note: For a comprehensive binding assessment and fixed price treatment and payment plan you need to come into one of our clinics for a half hour complimentary consultation and test patch.
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All fields are required
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Any information you have given regarding this consultation form is used as a guide only. This will be used by our clinic to essentially give you a much more accurate treatment plan. |
