Title:

Ms. Mr. Mrs. Title

First Name: (Required)

Last Name: (Required)

 

Street:

Apt. #

City:

State:

Zip Code:

Home Phone: (Required)

Work Phone:

Cell Phone:

From the pull down menu please select the desired office location:

Select a Location Manhattan Commack Queens

What is the color of the hair to be removed?

Black Brown Reddish-brown Light-brownLight-blond Red White Gray

Area parts to Treat: (check all that apply)

Upper Lip  Chin Face Neck  Under Arms Arms Shoulders
Upper Back Lower Back Chest Abdomen Bikini Area Buttocks
Upper Leg Lower Leg

What is your skin type?

	Type I- Always burns in the sun.  Never gets tan.
	Type II – Always burns, tans with difficulty.
	Type III – Burns mildly, tans slowly.
	Type IV – Rarely burns, tans with ease. Could be Asian, Asian or Hispanic descent, or of Hispanic descent
	Type V - Almost never burn.  Get dark in the sun. Could be Mediterranean, Asian, Hispanic or other descent.  Dark skin and hair.
	Type VI – Very dark.  Never burns.  Possibly African-American or Indian.

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Are you pregnant or nursing? Yes No

Are you diabetic? Yes No

      Yes No

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

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