You can be hair free sooner than you think!

Get started today. Complete the following questionnaire to find out if you are a candidate for Laser Hair Removal. All information is STRICTLY CONFIDENTIAL.

Required fields are marked with an *.

* 1. What body area are you considering for laser hair removal?

* 2. What have you previously used to remove your unwanted hair? Please select all that apply (hold ctrl key to select multiple options).

* 3. What color is your hair in the area you want it to be treated?

* 4. What color is the skin in the area you want to be treated?

* 5. Do you have a sun tan?

* 6. What is your skin type in the area you are considering to have laser hair removal?

	Type I - Always burn, never tan (extremely fair skin/blonde hair/blue/green eyes)
	Type II - Usually burn, tan less than about average (fair skin, sandy brown to brown hair, green/blue eyes)
	Type III - Sometimes mild burn, tan about average (medium skin, brown hair, green/brown eyes)
	Type IV - Rarely burn, tan more than average (olive skin, brown/black hair, dark brown/black eyes)
	Type V - Moderately pigmented, tans profusely (dark brown skin, black hair, black eyes)
	Type VI - Deeply pigmented, never burns (black skin, black hair, black eyes)

* 7. Have you been on Accutane in the past 6 months?

	Yes
	No

* 8. Are you currently on any medication?

	Yes
	No

9. If yes, does it cause photosensitivity?

	Yes
	No
	Not Sure

10. What is the name of the medication?

11. Any other questions you would like answered:

Personal Information. Please fill in the appropriate information for better service.
All information is strictly confidential. Required fields are marked with an *.

* Name:

* Address:

* City:

* State:

* Zip Code:

* Phone Number:

* How did you hear about us?

* Would you like a free brochure mailed to you?

Yes

* What e-mail address would you like the analysis results sent to? (E-mail must be provided to receive information!

The North Shore Laser Center
6 Essex Center Dr. Suite 206
Peabody, MA 01960