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New Image Laser Cosmetics utilizes multiple Laser and Light Systems as well as offering many other skin care services and products. To better assist you, we ask that you complete and submit this form. In this way we will be better prepared for your appointment and can be more specific with answering your questions.

First Name:
Last Name:
Daytime phone:
E-mail:
May we contact you at your e-mail address?	Yes No

What service or product are you interested in?	BOTOX to Flatten and Prevent Wrinkles Enhanced Skin Rejuvenation Collagen Augmentation Wrinkles Skin Toning or Pore Size Reduction Facial Redness Brown Spots Sun Damage Spider Veins / Leg Veins Hair Removal Shaving Bumps / Ingrown Hair Tattoo Removal Chemical Peels Laser Peels Medical Microdermabrasion Acne Treatment Cosmetic Products
The following questions help us to determine your skin type and therefore what laser system or products you may be a candidate for:

My eye color is:	Light Blue Blue / Green Green / Grey / Golden Hazel / Light Brown Brown / Dark Brown

My natural hair color at age 18 was:	Red Blonde Light Brown Dark Brown Black

The color of my skin that I do not normally expose to sunlight (eg. breasts, bikini area)	Pink to reddish Very Pale Pale with a beige tint Light Brown Medium to dark brown Dark brown-black

If I go out into the sun for an hour or so without sunscreen and have not been out in the sun for several weeks, my skin will:	Burn, blister and peel Burn, then when the burn resolves there is little or no color change Get Pink, but then turns to tan quickly Just Tan Gets very Dark My skin color is so dark, I can't tell

When was the last time the area to be treated was exposed to natural sunlight for a prolonged period of time (over an hour), tanning booths, or artificial tanning creams?	Longer than one month ago Within the past month Within the past two weeks With the past week