Laser Cosmetic Treatments - Clinton Twp., MI

Fill out the information below and submit the questionnaire to Advanced Laser Technology. After the form has been submitted you will receive an e-mail regarding your questionnaire results.

Your e-mail and all questions are required to submit the form.

Name:

E-Mail:

Please select your eye color:

Light Blue, Gray, Green:
Blue, Gray-Green:
Blue:
Dark Brown:
Brownish-Black:

Please select your natural hair color:

Sandy Red:
Blond:
Chestnut / Dark Blonde:
Dark Brown:
Black:

Please select your skin color:

Reddish:
Very Pale:
Pale w / Beige Tint:
Light Brown:
Dark Brown:

Please select how many freckles :

Many:
Several:
Few:
Incidental:
None:

Please select how you react to being in the sun too long:

Painful Redness:
Blistering, then Peeling:
Burn Sometimes, then Peeling:
Rarely Burns:
Never had a Burn:

Please select the degree in wich you turn brown from being in the sun:

Hardly / Not at All:
Light Color Tan:
Reasonable Tan:
Tan Very Easily:
Turn Dark Brown Quickly:

Please select if you turn brown from being in the sun within serveral hours:

Never:
Seldom:
Sometimes:
Often:
Always:

Please select your face's sensitivity to sun:

Very Sensitive:
Sensitive:
Normal:
Very Resistant:
Never had a problem:

Please select when your last exposeure to Sun, Sunlamp, or Tanning Cream was:

3+ Months Ago:
2-3 Months Ago:
1-2 Months Ago:
Less Than 1 Month Ago:
Less Than 2 Weeks Ago:

Please select how often the area to be treated is exposed to the sun:

Never:
Hardly Ever:
Sometimes:
Often:
Always:

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