Laser Hair Removal Questionnaire

Treatment Details:

Have you ever had laser hair removal before?

Yes
No

What areas of the body are you interested in treating?

Please select all that apply

Please specify

How would you describe your skin type?

What is your natural hair color?

Please specify

Health and Lifestyle:

Do you have any medical conditions that may affect your skin?

Yes
No

e.g., eczema, psoriasis

Please specify

Are you currently taking any medications that affect your skin sensitivity?

Yes
No

e.g., Accutane, Retin-A

Please specify

Do you have any known allergies, particularly to light-based treatments or any skincare products?

Yes
No

Please specify

Are you currently pregnant or breastfeeding?

Yes
No

Goals and Expectations:

What is your primary goal with laser hair removal?

Permanent hair reduction
Smoother skin
Reduce ingrown hairs
Other

Please specify

Are you interested in proactive healthcare and preventative measures to optimize your health and longevity?

Yes
No

Do you stay active and prioritize healthy lifestyle habits like exercise and nutrition?

Yes
No

Would you be open to exploring evidence-based, cutting-edge therapies for anti-aging and wellness?

Yes
No

Are you comfortable providing recent blood work or participating in a comprehensive health assessment?

Yes
No

Do you believe in a collaborative approach to healthcare, working with medical professionals to achieve your goals?

Yes
No

How much do you budget for beauty and wellness each year?

Less than $1000
Less than $10,000
More than $10,000

We know this question may feel personal—but it's important. It helps us prioritize patients who are committed to long-term results, and tailor recommendations that make sense financially and medically.

In the last 3–6 months, what’s been the most frustrating part about your health, energy, or appearance? Please be as specific as possible

(numbers on the scale, lab results, clothes that don’t fit, comments from others, photos you didn’t like, etc.).

Can you describe a recent moment when this problem really bothered you or got in the way of your life? What happened, and how did it make you feel?

Enter your zip code

We need to make sure your state allows telehealth.

Name

First

Last

Email

Phone

How did you hear about us?

Please specify

Our clinic is located in Hallandale, Florida, are you nearby?

Yes
I can make it
No, but I'm OK with a virtual consultation

If you live far, we do offer virtual consultations