First Name*

Last Name*

Date of Birth*

Age*

Gender*

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Work Phone

Email*

Your email address will be used for appointment confirmations, quarterly newsletters, and to alert you of specials and promotions.

Occupation

How were you originally referred to Bella Via?*

If Friend/Other, who referred you?*

Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours?*

Are you currently using Tazorac, Retin-A, Renova, or Differin?*

What Strength?*

How Frequently?*

For How Long?*

Where do you apply it?*

Have you ever been on Accutane? If yes, how long ago?*

Are you currently using any other skin thinning products and/or drugs?*

Are you diabetic?*

Please list any other illness or condition you are currently being treated for by a medical professional concerning the area to be treated.*

Please list any allergies, or sensitivities.*

Write n/a if none.

When was the last time you have waxed/tweezed/shaved?*

Wax Services Intake Form