Makeup / Tint Intake Form Personal Information Additional Information Twitter Full Name * DOB * Age * Gender * Address City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * Home Phone Cell Phone * Work Phone Email Address * 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? Dr. Colville Dr. Zavell Website Friend Other Have you ever used or do you currently use mineral-based cosmetics? * Yes No What is the main reason for your appointment today? * Do you have any allergies to peanut oil, lanolin, or sunflower oil? * Yes No Do you wear prescription or cosmetic contact lenses? * Yes. I understand I must remove them prior to lash tinting. No If yes, you must remove them prior to lash tinting I consent to having “Before” and “After” photographs of said procedure(s) for the purpose of documentation in my file. * These photographs MAY be used anonymously on your website or in your brochure for advertising purposes. These photographs MAY NOT be used anonymously on your website or in your brochure for advertising purposes. Authorization I authorize Bella Via Skin and Body Therapies to apply lash tinting to a minor under the age of 18.