Please complete the following form and after review by one of our physicians you will be emailed a skin health analysis, complete with recommendations you can implement to improve the health and beauty of your skin. The privacy of your information is extremely important to LaserMed. Your personal information will remain confidential and will not be shared with any other party. It is against our policy to contact you via telephone regarding this skin analysis unless you request phone contact below. Contact Information * First Name  Address Line 1  * Last Name  Address Line 2  Date of Birth  \ \ * City  Day Phone  * State  Evening Phone  * Zip Code  * Email Address  How did you find our website?  My PhysicianMedical JournalMagazine ArticlePrint AdRadio AdTV AdWeb SearchYellow Pages Skin Type Select the option that best describes your skin type  Oily  Oily to Normal  Normal  Normal to Dry  Dry  Combination  Problem/Blemished  Sensitive Skin Tone Select the option that best describes your skins reaction to sun exposure  Fair Skined: burns easily, never tans  Olive Skin: rarely burns  Light Skinned: will tan but usually burns  Dark Olive: very rarely burns  Light Olive: sometimes burns  Black: burn resistant Facial Lines / Wrinkles For each of the following areas rate your severity Fine Medium Deep None Crows feet at corner of eyes when face is at rest   Crows feet at corner of eyes when smiling   Glabellar crease between eye brows when furrowed   Glabellar crease between eye brows when face is at rest   Horizontal lines on forehead when face is at rest   Horizontal lines on forehead when eyes are showing surprise   Naso-labial folds (lines from corner of nostrils to corner of mouth) when face is at rest   Marionette lines (corner when face is at rest)   Marionette lines when smiling   Radial lip lines (certical creases between lip and nose) when face is at rest   Radial lip lines when lips are puckered   Platysmal creases (vertical lines around neck) when head is at rest   Platysmal creases when chin is raised up   Facial Sagging Skin For each of the following areas rate your severity A Little Some A Lot None Upper eyelids   Under eye bags   Near jaw line (jowls)   Under chin   Areas of Discoloration Small Medium Large For each of the following areas rate your severity   Light Dark Light Dark Light Dark None Freckles on face   Freckles on chest   Splotchiness on face   Splotchiness on chest   For each of the following, select the button that applies to your skin.   Whiteheads Blackheads Cystic Combination None Acne   Sun Damage   Mild Severe None On Face   On Chest   On Arms   On Legs     Isolated Overall Non-Existent Enlarged Pores on Face     Mild Severe Severe with Bumps None Flushing on Face (Rosacea)     Cheeks Only Cheeks & Nose None Broken Capillaries / Visible Veins     Acne Post Trauma Post Surgical None Scarring   Unwanted Hair Habits Select all that apply  Currently Used To Neither Smoke Cigarettes   Drink Alcohol   Sunbathe   Spend a lot of time in direct sunlight   Use sunscreen daily   Final Steps Other questions you would like to discuss I would like to be contacted to schedule a consultation with a doctor. Type your additional questions here. Yes   No Please include me on your skin care newsletter distribution list. Yes   No