Center for Laser & Electrolysis Hair Removal

Safe, Permanent Hair Removal for Men & Women

Please complete this form so that we can determine the best treatment for you. We will contact you promptly.
*The field marked with () are required fields.**
*	Please check your preferred title:	Miss Ms. Mrs. Mr.
*	Please enter your first and last name:
*	Please enter your complete mailing address:
*	Please enter your daytime telephone number:
*	Please enter your e-mail address:
*	Do you have fair skin and dark hair in the area you wish to have treated?	YES NO
*	Do you sunburn easily?	YES NO
*	What area(s) are you interested in treating?	Bikini Line Full Bikini Fingers Sideburns Knees Buttocks Thighs Lower Legs Breasts Forehead Toes Feet Chest Shoulders Chin Upper Lip Hands Abdomen Full Legs Back Cheeks Neck (hairline) Underarms Upper Arms Forearms (below elbow) Ears Periphery
*	Are you currently tanned in the area you wish to have treated?	YES NO
*	Have you taken the prescription medication Accutane in the past six months?	YES NO
*	If treatment is planned for the facial area, have you ever had a cold sore or fever blister?	YES NO
*	Please rate your skin type based on the following scale and your personal experience:	TYPE I (Always burn, never tan) TYPE II (Usually burn, tan with difficulty) TYPE III (Sometimes burn, tan about average) TYPE IV (Rarely burn, tan easily, above average)
*	How did you hear about Center for Laser & Electrolysis Hair Removal?
	If you have any special comments, concerns or questions, please enter them here: