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Micropigmentation
Laser Hair Removal
Vein Therapy
Request Consult

1412 South 7 Hwy.
Suite E
Blue Springs, MO 64014

Phone:
(816)220-7773
Fax:
(816)220-2272

Email: cindy@merrill
permanentcolor.com

 

Vein Therapy -
Request for Consult

In order to serve your needs better, please complete this consult form. We will determine you suitability for laser hair removal treatment, and our office will contact you within 48 hours with recommendations.

 REQUIRED FIELDS ARE IN RED

Title Mr. Ms. Mrs.
First Name
Last Name
Address
City
State
Zip
Are you over 18? Yes No
Can we contact
you by phone?		 Yes No
Daytime Phone
Evening Phone
EMail Address
   
Which areas on the body
would you like to be treated?:		 Face
Legs
    Other
 
Skin Tone: Light Toned
Medium Toned
Dark Toned
Last Sun/UV (tanning salon) exposure:
Do you use sunscreen when you are in the sun? Yes No
Do you use any retinoid cream or other skin preparation? Yes No
Have you ever been diagnosed with? Rosacea
Acne Rosacea
Seborrheic Dermatitis
     Location
Skin Cancer
     Location
Perpheral Vascular Disease   
Diabetes
Have you ever had any prior vein treatments? Yes No
If yes which area:
Type of treatment: Laser
IPL
Scleratherapy
Other
If you are diabetic, have you ever had any problems with your legs / feet or wounds healing? Yes No
Do you have pain in your lower legs or feet after walking 50 feet or more? Yes No
Number of treatments
Length of time since last treatment:
Were you happy with the results: Yes No
If yes, Explain:
Any problems following procedure: Yes No
If yes, Explain:
Any special concerns or extra questions:
   

    

 

 


We maintain a full line of LA ROCHE - POSAY products in our office.  Click HERE for more information.


Directions and a Map to our location can be found HERE.


Check out our supporting sites!


Check Here for Frequently Asked Questions


Click to see our specials from:

FEIST
or
VAL-PAK

 


It is our goal to provide you with professional services to help you look your very best.
 

We offer FREE consultations to all new clients!
$50 value

  

 

 

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