Name *

First Name

Last Name

Phone

(###)

###

####

Best time of day for us to call?

Morning 10am-12pm

Afternoon 12pm-5pm

Evening 5pm-8pm

ARE YOU OVER THE AGE OF 18? *

Yes

No

DO YOU UNDERSTAND THAT THERE CAN BE NO SUN EXPOSURE (COVERED OR FACTOR 50 SUNSCREEN) IN THE TREATED ARE FOR 4-6 WEEKS BEFORE AND AFTER LASER HAIR REMOVAL? * *

Yes

No

DO YOU HAVE ANY ACTIVE SKIN CONDITIONS IN THE AREA YOU WISH TO TREAT (E.G., ECZEMA, PSORIASIS, OR OPEN WOUNDS)? *

Yes

No

ARE YOU CURRENTLY PREGNANT OR BREASTFEEDING? *

Yes

No

DO YOU HAVE A HISTORY OF KELOID SCARRING OR HYPERTROPHIC SCARS? *

Yes

No

ARE YOU TAKING ANY MEDICATIONS THAT INCREASE SENSITIVITY TO LIGHT (E.G., ACCUTANE, CERTAIN ANTIBIOTICS)? *

Yes

No