First Name
Last Name
Address
City/State/Zip
Telephone
Fax
E-mail
What best describes your skin type?
.....Check list.....
Always burns, never tans (extremely fair skin,blonde hair, blue/green eyes)
Usually burns, tans less than about average (fair skin, sandy brown to brown hair, green/blue eyes)
Sometimes mild burn, tans about average (medium skin, brown hair, green/brown eyes)
Rarely burns, tans more than average (olive skin, brown/black hair, dark brown/black eyes)
Moderately pigmented, tans profusely (dark brown skin, black hair, black eyes)
Deeply pigmented, never burns (black skin, black hair, black eyes)
What body area(s) would you like treated?
.....Check list.....
Abdomen
Arms
Back
Bikini
Buttocks
Chest
Face
Feet
Legs
Neck
Under Arms
Other
Are you pregnant or nursing?
yes
No
Are you a diabetic?
yes
No
Check here if you use any medication and
if so please list below!
What methods of hair removal have you used in the past?
Please describe results?
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