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YesAfter 1 hr of sun exposure do you...(Required) Always Burns/Never Tans Always Burns/Sometimes Tans Sometimes Burns/Sometimes Tans Rarely Burns/Always Tans Brown, Moderately Pigmented Skin Dark SkinPlease select which best applies to youEthnic background (for skin typing/laser safety purposes)(Required)When were you last in the sun, tanning bed or used self tanners?(Required)Which service are you interested in?(Required) Body Sculpting (Emsulpt or Coolsculpt) Anti-Aging Treatments Scar Removal Pigmentation Treatments Laser Hair Removal Spider Vein Removal Hair Loss Treatments Tattoo Removal Botox Or Fillers Stretch Mark Removal Cellulite Treatment Erectile Dysfunction or Penis Enlargement Acne Treatment Mole or Skin Tag Removal Eye TreatmentsSelect at least one service interestDo you have diabetes or a bleeding disorder?(Required) Yes NoDo you have or have you had any type of cancer?(Required) Yes NoHave you had any recent surgeries?(Required) Yes NoProne to keloid scarring?(Required) Yes NoDo you wear contact lenses?(Required) Yes NoDo you have permanent make-up or tattoo?(Required) Yes NoSkin diseases/skin lesions?(Required) Yes NoNeurological disorder or seizure disorder?(Required) Yes NoUticaria/Lupus(Required) Yes NoProne to Herpes Simplex/Cold sores(Required) Yes NoThyroid imbalance?(Required) Yes NoHeart disease? Pace maker?(Required) Yes NoBlood pressure/Circulation difficulties?(Required) Yes NoAnticoagulant/Blood clotting?(Required) Yes NoAre you pregnant or lactating?(Required) Yes NoHIV/AIDS virus?(Required) Yes NoAccutane/Tazorac/Avege?(Required) Yes NoAre you a smoker?(Required) Yes NoDo you have vitiligo?(Required) Yes NoDo you use Retin-A products?(Required) Yes NoDo you have any hernias?(Required) Yes NoAre you photosensitive or on photosensitizers?(Required) Yes NoHave you had Botox/Juvaderm/Restylane?(Required) Yes NoDo you form thick raised scars from cuts or burns?(Required) Yes NoDo you hyperpigment or hypopigment after physical trauma?(Required) Yes NoDo you get rashes from heat exposure?(Required) Yes NoDo you have history of livido reticularis?(Required) Yes NoDo you have any known allergies?(Required) Yes NoIf you selected yes please list your allergiesPlease tell us any medication you are taking or medical conditions/problems you may havePlease choose which applies to you I would like to be contacted for a consultation I made an online purchase and I am now filling out a consultation form I already contacted Bellair via the contact form/email or phoned in for a consultationFailure to disclose full medical information may result in complications(Required) I certify that all medical information provided is trueDate(Required) Signature(Required) Bay & Bloor (416) 972-0337 116 Cumberland Street, Toronto ON M5R 1A6Yonge & Eglinton (416) 489-0337 2237 Yonge Street, Toronto ON M4S 2B8Hours Of Operation Monday – Friday 9:00 AM to 8:00 PM Saturday 9:00 AM to 6:00 PM Sunday ClosedServices About Prices Financing Contact Services About Prices Financing ContactHours Of Operation Monday – Friday 9:00 AM to 8:00 PM Saturday 9:00 AM to 6:00 PM Sunday ClosedBay & Bloor (416) 972-0337 116 Cumberland Street, Toronto ON M5R 1A6Yonge & Eglinton (416) 489-0337 2237 Yonge Street, Toronto ON M4S 2B8