Laser Treatment Inquiries

Although there is no substitute for a face-to-face consultation, we can often help determine whether you are a suitable candidate for a specific procedure by viewing your photos.

It is important that you send us images of sufficient quality so that we can adequately assess your cosmetic concerns. Please review the General Photo Taking Guidelines at the bottom of this form prior to uploading photos.

Legal Name *

Preferred Name or Nickname *

When were you born (MM/DD/YYYY)? *

E-mail *

Telephone *

Zip Code *

How do you prefer to be contacted? *

E-mail
Telephone call

Do you already have a consultation scheduled? *

Please use the below check boxes to share your primary concerns.

Skin Quality (select all that apply) *

Loss of elasticity
Loss of skin luster
Sagging skin
Thinning skin
Dry skin

Skin texture (Select all that apply) *

Acne scars
Fine lines / Wrinkles
Large pores
Bumpy skin
Oily skin
Stretch marks

Skin coloration (select all that apply) *

Age spots
Dark spots
Freckles
Uneven complextion
Redness / Facial flushing
Spider veins

Other concerns *

Feminine rejuvenation
Hair removal
Tattoo removal
Underarm sweat/odor reduction

Please provide details regarding the areas of concern you selected above. *

Please provide details regarding any past treatments you've had to address these concerns. When was the last treatment? What were your results? *

Please tell us about your skin type and how your skin reacts to the sun by choosing the skin type that describes you the best. This information helps us in choosing the most appropriate treatment option for you. *

Pale white skin, blonde/red hair, always burns, never tans
Fair skin, blonde/light brown hair, burns easily, tans poorly
White/light brown skin, chestnut/dark blonde hair, sometimes burns, gradually tans
Medium brown/dark brown skin, brown/dark brown hair, rarely burns, tans easily
Dark brown skin, dark brown hair, very rarely burns, tans easily and quickly darkens
Black skin, black hair, never burns, tans very dark

Use the above "browse" button to upload files. To select multiple files, use the Control (Windows) or Command (Mac) and click on each file you'd like to upload prior to clicking "Add". To select multiple photos from a mobile device, please select all photos prior to clicking "Add". Once you click Add, you will not be able to upload more photos on the same form. If you accidentally click Add and want to add more photos, please remove the photo then re-add them. Limit: 8MB

Upload Photos. *

Please don't use any spaces or special characters (# % & { } \ < > * ? / $ ! '" : @) in the name of the image files.

General Photo Taking Guidelines

Have another person take your photos or use a camera timer. Selfies and selfie-sticks are from too close of a distance and therefor distort proportions and resolution. Use a solid color background without any objects (a plain wall works great). For face/neck, make sure eyeglasses are off and hair is pulled away from the face as much as possible. Orient the camera vertically so that the framed picture is a vertical rectangle (higher up/down than side/side) instead of a horizontal rectangle. Take photos facing the camera straight-on, at 45-degrees (3/4 view), and 90-degrees (side-view).