Bella Via Medical Spa
2865 N Reynolds Rd #240
Toledo, OH 43615
Phone: (419) 534-6552
Monday, Wednesday, Friday: 8:30 a.m.–6 p.m.
Tuesday, Thursday: 8:30 a.m.–7 p.m.
Every other Saturday: 9 a.m.–4 p.m.

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Injectable Consult/Treatment Intake Form

Injectable Consult/Treatment Intake Form

Name: Bella Via Medical Spa
Address: 2865 N Reynolds Rd #240, Toledo, OH, 43615
Telephone: (419) 534-6552

"*" indicates required fields

First Name*

Last Name*

Date of Birth*

Age*

Gender*

Email*

Your email address will be used for appointment confirmations, quarterly newsletters, and to alert you of specials and promotions.

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Mobile Phone*

Work Phone

Occupation*

How were you originally referred to Bella Via?*

If Friend/Other*

Medication/Supplements/Vitamins*

Be sure to include doses and reasons for taking each. If none, write "none".

Allergies*

List any known allergies and your reaction. If none, type "none".

Facial Implants*

List any facial implants. If none, type "none".

Do you have a history of cold sores/herpes?*

Botox/Xeomin/Dysport*

Have you had Botox/Xeomin/Dysport in the past? If so, how long ago? If no, write "no".

Dermal Filler*

Have you had any dermal filler in the past? If so, how long ago? If no, write "no".

Dental Procedures*

Have you had any dental procedures within the past 2 weeks or do you have any upcoming dental procedures?

Tobacco/Nicotine/Vaping*

If yes, how often/much? If no, write "no".

Cannabis/Marijuana/CBD*

If yes, how often/much? If no, write "no".

Female patients: are you currently pregnant or breastfeeding?*

Height*

Weight*

Additional Information

Anything else you would like your provider to know regarding your health or past experiences?

Signature*

Enter your full name. By entering your name below and submitting this form you agree the information you provided is truthful and accurate to the best of your knowledge.