ADDRESS

Is your skin tanned ?
  Yes       No

Services desired
  Laser Hair Removal    
  Rosacea/Diffuse Redness     
  Skin Tightening    
  Toenail Fungus    
  Pigmented Lesion Removal    

Color of hair to be removed
  Black       Brown       Reddish-brown       Light-brown       Light-blond       Red       White       Grey    

Gender
  Female       Male    

Skin Type
  Type I: Always burns, never tans
  Type II: Always burns, sometimes tans
  Type III: Sometimes burns, always tans
  Type IV: Rarely burns, always tans
  Type V: Brown, moderately pigmented skin
  Type VI: Black/ Very dark brown skin

Are you taking, or have you taken Accutane in the last six months?
  Yes       No

Are you taking any medication that causes photosensitivity?
  Yes       No       Not Sure

If you are not sure, which medicines are you taking?

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