Online Laser Questionnaire

1. What body area are you considering for laser hair removal?
Abdomen Abdomen Line Arms-Full Back-Full Back-Partial Bikini-Brazilian Bikini-Full Bikini-Swimsuit Breast-Full Breast-Areola Chest Chin Ears-Full Ears-Partial Face-Full Feet/Toes Forearms Full-Beard-No-Neck Full-Beard-With-Neck Glabella (between eye-brows) Gluteal Hands/Fingers Legs-Full Legs-Upper Legs-Lower Miscellaneous Neck-Back Neck-Front Shoulders Under-Arms Upper-Lip

   Additional areas to be treated:

2. What is your gender
Female Male

3. What have you previously used to remove your unwanted hair? Please select all that apply.
Nothing Waxing Tweezing Shaving Nair, Epilstop Bleaching

4. What color is your hair in the area you want to be treated?
Black Brown Blonde Grey White Light Brown Light Blonde Red

5. What color is your skin in the area you want to be treated?
Black Brown White Light Brown

6. Do you have a sun tan?
Tan Slight Tan No Tan

7. 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)

8. Have you been on Accutane in the past 6 months?
Yes No

9. Are you currently on any of the following medications: Antibiotics, Sunscreens wih PABA, specific Herbal and Anti-Inflammatory Medicines?
Yes No

10. If so, what is the name of the medications?

11. If yes, is it photosensitive?
Not Sure Yes No

12. Any other questions or concerns you would like to ask.

Personal information to be completed, so we may better serve you. For a FREE brochure and services information, please complete your address in its entirety. All Information is strictly confidential!

Name:

Address:

City:

State:
Alabama Alaska Alberta Arizona Arkansas B. C. California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Terr. Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Ed. Is. Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon

Zip Code:

Telephone:

Best time to call you:
Afternoon Lunchtime Evening Other

Would you like a free brochure mailed to you?
Yes No

The email address you would like any replys to this form to be sent to.

Laser Elite Centre and its staff, would like to thank you for your interest in our centre. We look forward to meeting you soon, if you have any further questions or concerns, please do not hesitate to call our office at 703.760.5126

"Come Experience the Art of Laser Elite Centre" won’t you…………

It is important to us, to be able to offer our patients state-of-the-art services and techniques; but, at the same time we wish to assure you that your needs and concerns, before your first visit, during and after become our first priority.

Safety of our patients, is our prime concern at Laser Elite Centre. In addition to, we pride ourselves on providing each patient with outstanding personal care; this is what has set us apart from the competition.

There will be no compromising........

The staff at Laser Elite Centre are excited to meet you. We will assist each patient with their questions and/or concerns with Laser Hair Removal, Skin-Tightening, MicroDerm Abrasion or one of our many other skin care services; it has always been our ultimate goal to provide you with exceptional care at an affordable cost to you.

That alone, will ultimately make a difference in your tomorrow.

For those wishing a translator, Arabic, English, Farsi, German and Turkish are spoken by our staff.

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