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Photo Rejuvenation Online Consultation

Our Free Online Consultation is a quick and confidential way to find out if you are a good candidate for Photo Rejuvenation treatments.

1. What area are you considering for Photo Rejuvenation treatment?
2. Do you have any medical conditions?
3. Are you currently taking any medications?
Yes No

What is the name of the medication?
(Please list any an all medications, including natural products such as St-John's Wort)
4. What color is your skin in the area you want to be treated?
5. Do you have a sun tan?
6. What is your skin type in the area you are considering for photorejuvenation?
7. Have you been on Accutane in the past 6 months?
Yes No
8. What is your sex?
M F
9. Personal information. (All Information is Strictly Confidential!)

Name
*
Phone Number
*
E-mail address
*

Would you like us to call you?
Yes No

Would you like a free brochure?
Yes No

Address

City

Province / State

Zip Code/ Postal Code

Country
We will respond to your request via e-mail

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