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Reflections Center For Skin and Body, Mitchell Chasin, MD
Bridgewater, NJ

Clinic Details:
Reflections Center For Skin and Body, Mitchell Chasin, MD

Specialty:	Laser Hair Removal
Contact:	Mitchell Chasin
Phone:	908-575-1122
Address:	350 Grove Street at Route 22 East Bridgewater, NJ 08807
Office Hours:

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Reflections Center For Skin and Body, Mitchell Chasin, MD (Bridgewater)
Reflections of Livingston (Livingston)

Contact Reflections Center For Skin and Body, Mitchell Chasin, MD:

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Title:

Name (first/last):

Email Address:

Phone Number:

For a more detailed evaluation and to save 10% off your first treatment (at participating clinics) complete the entire consultation form.

Street Address:

Apt #:

City:

State:

Zip Code:

Is your skin suntanned? (Check if yes.)

Color of hair to be removed:

Black
Brown
Reddish-brown
Light-brown

Light-blond
Red
White
Gray

Gender:

Female

Male

Areas to treat (check all that apply):

Upper Lip
Chin
Face
Neck
Under Arms

Arms
Shoulders
Upper Back
Lower Back
Chest

Abdomen
Pubic Area
Buttocks
Upper Leg
Lower Leg

Skin type:

Type I: Always burns in the sun. Never gets tan. Fair skin, light eyes.
Type II: Sometimes burns, but it turns to tan. Fair skin, medium to dark eyes, light brown- brown hair.
Type III: Usually tans, can burn as well. Medium skin; medium to dark eyes, brown hair.
Type IV: Seldom burns. Possibly Mediterranean, Asian or Hispanic descent. Olive skin, dark eyes, brown black hair.
Type V: Almost never burns. Get dark in the sun. Possibly Mediterranean, Asian, Hispanic or other descent. Dark skin, hair and eyes.
Type VI: Very dark. Never burns. Possibly African-American, Indian or West Indian descent.

Are you taking, or have you taken Accutane in the last six months?

Yes

Are you taking any medication that causes photosensitivity?

Yes

Not sure

If you are not sure, which medicines are you taking?

Additional Comments:

Please include the color of the hair to be treated, your skin type (click here for skin type chart), the areas to be treated and any other information you think is important.

There are other questions that will be asked when you come in for your consultation, but these give us some of the basic information that we need.

Reflections Center For Skin and Body, Mitchell Chasin, MDBridgewater, NJ

Contact Reflections Center For Skin and Body, Mitchell Chasin, MD:

Reflections Center For Skin and Body, Mitchell Chasin, MD
Bridgewater, NJ