Bay & Bloor LocationPlease enable JavaScript in your browser to complete this form. - Step 1 of 5Name *FirstLastEmail *Phone *Address *Address Line 1Address Line 2CityState / Province / RegionPostal Code--- Select country ---AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryMay we send you correspondence?YesNextAfter 1 hr of sun exposure do you... *Always Burns/Never TansAlways Burns/Sometimes TansSometimes Burns/Sometimes TansRarely Burns/Always TansBrown, Moderately Pigmented SkinDark SkinPlease select which best applies to youEthnic background (for skin typing/laser safety purposes) *When were you last in the sun, tanning bed or used self tanners? *Which service are you interested in? *Body Sculpting (Emsulpt or Coolsculpt)Anti-Aging TreatmentsScar RemovalPigmentation TreatmentsLaser Hair RemovalSpider Vein RemovalHair Loss TreatmentsTattoo RemovalBotox Or FillersStretch Mark RemovalCellulite TreatmentErectile Dysfunction or Penis EnlargementAcne TreatmentMole or Skin Tag RemovalEye TreatmentsSelect at least one service interestNextDo you have diabetes or a bleeding disorder? *YesNoDo you have or have you had any type of cancer? *YesNoHave you had any recent surgeries? *YesNoProne to keloid scarring? *YesNoDo you wear contact lenses? *YesNoDo you have permanent make-up or tattoo? *YesNoSkin diseases/skin lesions? *YesNoNeurological disorder or seizure disorder? *YesNoUticaria/Lupus *YesNoProne to Herpes Simplex/Cold sores *YesNoNextThyroid imbalance? *YesNoHeart disease? Pace maker? *YesNoBlood pressure/Circulation difficulties? *YesNoAnticoagulant/Blood clotting? *YesNoAre you pregnant or lactating? *YesNoHIV/AIDS virus? *YesNoAccutane/Tazorac/Avege? *YesNoAre you a smoker? *YesNoDo you have vitiligo? *YesNoDo you use Retin-A products? *YesNoNextDo you have any hernias? *YesNoAre you photosensitive or on photosensitizers? *YesNoHave you had Botox/Juvaderm/Restylane? *YesNoDo you form thick raised scars from cuts or burns? *YesNoDo you hyperpigment or hypopigment after physical trauma? *YesNoDo you get rashes from heat exposure? *YesNoDo you have history of livido reticularis? *YesNoDo you have any known allergies? *YesNoIf 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 youI would like to be contacted for a consultationI made an online purchase and I am now filling out a consultation formI already contacted Bellair via the contact form/email or phoned in for a consultationFailure to disclose full medical information may result in complications *I certify that all medical information provided is trueDate *NameSubmit