Laser Hair Removal Intake Form

Step 1 of 4

Full 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?*

Which areas would you like to have treated?*

What results would you like to see from your treatment?*

Have you ever had any prior treatment to the affected area? If yes, approximately how long ago?*

What medications are you currently taking (including aspirin, vitamins, or herbal supplements):*

Do you have any allergies to medications? If yes, which ones?*

Write 'n/a' if not applicable.

When were you last exposed to the sun (including tanning booths)?*

Do you use chemical sun tanning lotions?*

When exposed to the sun without protection for about 1 hour, you:*

Are you pregnant?*

Do you have permanent makeup (lip liner, eye liner, etc.)?*

Do you take any herbal supplements (St. Johns Wort, etc.)?*

Do you have very dry skin?*

Do you have any active infections?*

Do you have a history of keloid scarring?*

Do you have any known history of hormonal or endocrine disorders, such as: polycystic ovary syndrome, diabetes, etc, that may not be under control?*

Do you have any known history of Immunosuppressive diseases, including AIDS and or HIV infection, or do you use any immunosuppressive medications?*

Do you have a current history of cancer, especially malignant melanoma, recurrent non-melanoma skin cancer, or precancerous lesions such as dysplastic nevi?*

Do you have a history of bleeding coagulopathies or use blood thinners?*

Do you have any diseases which may be stimulated by light, such as: cold sores (Herpes Simplex), Systemic Lupus Erythermatosus, etc.?*

One of the most important factors for the success of your treatment is the correct typing of your skin. Skin type is often categorized according to your genetic disposition, reaction to sun exposure, and tanning habits. Please answer the following questions below to help us determine your correct skin type.

Genetic Disposition

What is the color of your eyes?*

What is the natural color of your hair?*

What is the color of your skin (Non-exposed area)?*

Do you have freckles on unexposed areas?*

Hidden

Genetic Disposition Total*

Reaction to Sun Exposure

What happens when you are in the sun for too long?*

Do you turn brown within several hours after sun exposure?*

To what degree do you tan (turn brown)?*

How does your face react to the sun?*

Hidden

Reaction to Sun Exposure Total*

Tanning Habits

When did you last expose your skin to the sun? (Include tanning booths and/or self tanner)*

Did you expose the area to be treated to the sun?*

Hidden

Tanning Habits Total*

Hint and Wish List

Would YOU like a Bella Via gift card or your favorite skincare product as a gift for a holiday or special occasion? Sharing a wish list to close family and friends makes gift giving fun and less stressful! Fill out our Hint and Wish List and we will send it to your gift giver!

Laser Hair Removal Intake Form

Genetic Disposition

Reaction to Sun Exposure

Tanning Habits

Possible Side Effects of Treatment

Discomfort

Erythema

Change of Pigmentation

Blister

Bruising

Hint and Wish List

Hint and Wish List

Pin It on Pinterest