The Laser Clinic First-Time Patient Inquiry Form
Email address *
Your name: *
Your answer
Phone number: *
Your answer
How would you prefer to be contacted? *
What times and days in general would work best for you to come in?
Morning
Afternoon
Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What color hair is the area we might treat? *
What color is the skin in the area we might treat? *
Any special requests or concerns?
Your answer
How did you hear about us? *
If you were referred by a friend, who are they?
Your answer
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