Skincare Treatments Intake Form Personal Information Skin Specifics Health & Lifestyle Twitter Full Name * Please enter your full name DOB * MM-DD-YYYY 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 Mobile 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 Airline Travel Yes No What are your expectations of the skin treatment you will receive today? * If time allows, would you like to add any extra services to your skincare procedure today, such as waxing or paraffin for the hands and/or feet? * How would you describe your skin? (check all that apply) * Acne Scarred Asphyxiated Breakouts Combination Comedones Cysts Dry Firm Florid/Flushed Freckled Hyperpigmented Hypopigmented Large Pores Mature Melasma Milia Normal Oily Oily T-Zone Patchy Dryness Perfume-Stained Psoriasis Rosacea Saggy Sallow/Yellowed Small Pores Sun-Damaged Thick Uneven Wrinkled Telangiectasia (Broken Surface Capillaries) What type of skin do you have? * Sensitive Resilient Unsure Are you sensitive to alcohol-based products? * Yes No Have you ever had a peel? * Yes No Are you currently having microdermabrasion? * Yes No Have you recently had laser resurfacing? * Yes No Do you have regular collagen injections? * Yes No Do you have regular Botox injections? * Yes No Are you currently using Accutane? * Yes No Are you currently using Tazorac, Retin-A, Renova, or Differin? * Yes No Are you currently using Bioré/snore strips? * Yes No Do you wear contact lenses? * Yes No Do you tan via artificial tanning beds or booths? * Yes No Do you participate in vigorous aerobic activity or sports? * Yes No Are you pregnant or lactating? * Yes No (If yes, you may only receive the Oxy Trio or Detox treatment.) Have you had your hair colored in the last 3 days? * Yes No Do you plan on getting your hair colored in the next 3 days? * Yes No Do you use a buff-puff to cleanse your face? * Yes No Have you had facial waxing within the last 3-5 days? * Yes No Have you shaved your face within the last 3-5 days? * Yes No Do you smoke? * Yes No Do you develop cold sores and/or fever blisters? * Yes No Do you currently have a sunburned/windburned/red face? * Yes No Are you planning to attend a special event (wedding, reunion, other)? If so, when? * Please check all allergies and/or sensitivities: Aloe Vera Apples Aspirin Citrus Grapes Hydroquinone Latex Milk Perfumes Other Please list all drug allergies: What is your eye color? * What is your natural hair color? * What is your skin tone? * Pale/Fair Light Medium Reddish Freckled Light Olive Medium Olive Dark Olive Light Brown Medium Brown Dark Brown Soft Black Black Sallow/Yellowed What is your skin heritage? * Irish/English Nordic Russian Middle-Eastern Hispanic African Asian Italian Have you ever used any skincare products that caused a negative reaction? * Yes No List all skincare products that you are currently using: List all medications, herbals, and vitamins that you are currently taking: List all surgeries that you have had within the last five years and their approximate dates: Do you have or have you had any other medical condition(s) that your aesthetician should know about? If yes, please explain: What cosmetic improvements would you like to see in your skin? * By submitting this form, I agree to the following statement: I understand that my body therapy session is provided for the basic purpose of stress reduction, relief from muscular discomfort, and for help in increasing blood, lymph, and energy circulation. I have stated all known medical conditions and I will keep the massage therapist updated on any changes regarding my health. I claim full responsibility for services rendered. 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.