Urban Family Practice

Free Analysis Form

Fields marked (*) are required

First:*

Last:*

Email:

Telephone:

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.

Nothing
Waxing
Tweezing
Shaving
Nair
Bleaching
Other (please specify)
 

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

Black
Brown
Blonde
Grey
White
Light Brown
Light Blonde
Red

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

White
Brown
Black
Light Brown

5. Do you have a sun tan?

Tan
Slight Tan
No 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/blond 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
Other (please specify)
 

9. If yes, does it cause photosensitivity?

Yes
No
Not sure

10. What is the name of the medication?