Zeno - Clearly Outsmarts Pimples

Title:

Ms. Mrs. Mr.

Name:

First Mid. Initial Last

Street Address:

City:

State or Province:

Zip Code:

Daytime Telephone Number:

Email Address:

What color is the hair you wish removed?
Brunette Blonde Redhead Grey or White

Please describe its growth:
Heavy, dense & coarse Medium growth Sparse, light & fine

Which body areas would you like treated?
Face	Arms	Underarms	Bikini	Legs	Back
Neck	Chest	Abdomen	Toes	Other

Please describe your skin tone:

Very fair: always burn, never tan, blue eyes
Light skin: mainly burn, sometimes tan
Medium or olive complected: mainly tan, rarely burn
Dark toned: never burn, dark eyes, dark hair

Have you had either laser hair removal treatment or electrolysis before?
Yes No
If so, please tell us your results:

Please check any of these conditions that apply to you now:
Diabetic Pregnant

Please check if you are taking any of these medications :
Acne Medications (Accutane, Accutane derivative, etc.)
Anti Cancer Drugs	Anti Depressants
Antihistamines (Benadryl, Claritin)	Diuretics
Anti-Inflammatory (Naprosen, etc.)	Hypoglycemics
Herbals (St. John's Wort, etc.)	Antimicrobials
Hormonals (Birth control pills, etc.)	Antipsychotics
None of the above	Other

1513 W. Koenig Lane • Austin, Texas 78756 • 512.459.6353 • cpiquard@swbell.net