Laser Hair Removal / Virtual Test

Are you a good candidate for Laser Depilation?

Virtual test and consultation to establish whether you are a good candidate for laser depilation.

All the information facilitated is confidential.

By completing this form you will immediately receive confirmation by telephone or email about whether you are an ideal candidate for laser depilation and the equipment most suited to you.

This virtual test does not intend to be a substitute for informed medical advice and you should not take any action prior to consulting with a health professional.

IMPORTANT

• All information is confidential.
• Personal data is collected in this virtual consultation is only used to respond to it.
• Your data will be used only to receive the information you have requested, in accordance the law of the Data Protection Act 15/1999, of December 13, which refers to the protection of personal data (Act). In no case will be transferred this data to third parties or market to them, without their express permission. You can always exercise their right of access, opposition, rectification and / or cancellation thereof, in accordance with the provisions of current legislation on data protection. The data will be verified and any requests that contain false or misleading data will be discarded. View Privacitat Policy

The fields marked with * are obligatory.

Name: (*) Surname: (*)
E-mail: (*) CP: (*)
Telephone: (*)
1. What areas of your body would you like to depilate by laser? (*)
2. With which method have you most recently depilated? (*) Electric razor Wax Blade Bleaching Tweezers None
3. How long ago? (*)
4. What colour is the hair in the area you wish to depilate? (*) Black Brown Blonde Gray Red
5. Which of the following characteristics best describes your skin (see attached table) (*) I – White, Blonde II – Light, Blonde/Chestnut III – Brown, Chestnut IV – Very brown,Chestnut/Dark V – Dark, Black VI – Black, Black
6. Are you normally brown in the areas you wish to treat? (*) None Slight Much
7. When was the last time you were tanned (sun, UV rays or self-tanning creams)? (*)
8. Are you currently taking any medication which may provoke increased skin sensitivity or have you taken Accutane or any other type of acne medication? (*) Yes No
If you are taking any medication and you are not sure whether it is photo-sensitive, write the name in this box.
9. Do you suffer from any of these illnesses? (*) Diabetes Epilepsy Folliculitis Hirsutism Herpes Thyroid Problems Depression None
10. Are you pregnant or breast-feeding? (*) Yes No
11. Observations

I authorise the Clinical Capillary and Cosmetic Institute S.L. to send me publicity and promotional offers to the email address supplied and I confirm I have read and I accept the Privacy Policy clause.

Select the photo-type that best describes your type of skin from this table

Phototype	Hair	Eyes	Skin	Burns in the sun
I	blonde	blue/green	white	always
II	blonde/chestnut	green/brown	light	always
III	chestnut	browns/dark	brown	frequently
IV	chestnut/dark	dark	very brown	almost never
V	black	dark	dark	almost never
VI	black	black	black	never

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