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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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Laser Hair Removal Intake Form

Laser Hair Removal Intake Form

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

"*" indicates required fields

Step 1 of 4

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First Name*

First

Last Name*

Last

Date of Birth*

Age*

Gender*

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Work Phone

Email*

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?*

If Friend/Other, who referred you?*

Which areas would you like to have treated?*

What results would you like to see from your treatment?*

Have you ever had any prior treatment to the affected area? If yes, approximately how long ago?*

What medications are you currently taking (including aspirin, vitamins, or herbal supplements):*

Do you have any allergies to medications? If yes, which ones?*

Write 'n/a' if not applicable.

When were you last exposed to the sun (including tanning booths)?*

Do you use chemical sun tanning lotions?*

When exposed to the sun without protection for about 1 hour, you:*

Are you pregnant?*

Do you have permanent makeup (lip liner, eye liner, etc.)?*

Do you take any herbal supplements (St. Johns Wort, etc.)?*

Do you have very dry skin?*

Do you have any active infections?*

Do you have a history of keloid scarring?*

Do you have any known history of hormonal or endocrine disorders, such as: polycystic ovary syndrome, diabetes, etc, that may not be under control?*

Do you have any known history of Immunosuppressive diseases, including AIDS and or HIV infection, or do you use any immunosuppressive medications?*

Do you have a current history of cancer, especially malignant melanoma, recurrent non-melanoma skin cancer, or precancerous lesions such as dysplastic nevi?*

Do you have a history of bleeding coagulopathies or use blood thinners?*

Do you have any diseases which may be stimulated by light, such as: cold sores (Herpes Simplex), Systemic Lupus Erythermatosus, etc.?*

One of the most important factors for the success of your treatment is the correct typing of your skin. Skin type is often categorized according to your genetic disposition, reaction to sun exposure, and tanning habits. Please answer the following questions below to help us determine your correct skin type.

Genetic Disposition

What is the color of your eyes?*

What is the natural color of your hair?*

What is the color of your skin (Non-exposed area)?*

Do you have freckles on unexposed areas?*

Hidden

Genetic Disposition Total*

Reaction to Sun Exposure

What happens when you are in the sun for too long?*

Do you turn brown within several hours after sun exposure?*

To what degree do you tan (turn brown)?*

How does your face react to the sun?*

Hidden

Reaction to Sun Exposure Total*

Tanning Habits

When did you last expose your skin to the sun? (Include tanning booths and/or self tanner)*

Did you expose the area to be treated to the sun?*

Hidden

Tanning Habits Total*

Thank you for choosing Bella Via Skin and Body Therapies and Reconstructive & Aesthetic Surgeons, Inc. In our ongoing efforts to provide you with the best possible services, we ask that you carefully review this consent form and ask all questions necessary to help you fully understand it.

Consent 1*

I agree to the privaI understand that the purpose and use of the Lumenis LightSheer™ Diode Laser is intended for permanent hair reduction. The clinical results may vary due to skin type, patient tolerance, individual response to treatment, and patient compliance with pre- and post-treatment instructions.cy policy.*

Consent 2*

I understand a single treatment will most likely fail to completely remove all my unwanted hair in the area treated. Multiple treatments are required. Individual response will vary according to skin type, hair color, degree of tanning, follow-up care, and the body area being treated.*

Possible Side Effects of Treatment

Discomfort

Some patients experience various degrees of discomfort. Some have described the sensation as stinging, while others have described as similar to a rubber band snap.

Erythema

The most common side effects are erythema (redness) and mild edema (swelling), which generally occur immediately after laser treatments and typically resolve within 24 to 48 hours.

Change of Pigmentation

There may be a change of pigmentation in the treated area. Most cases of hypo- (lighter) or hyper- (darker) pigmentation occur in people with darker skin, or when the treated area has been exposed to sunlight before or after treatment. In some patients, hyper-pigmentation occurs despite protection from the sun. This discoloration usually fades in three to six months, but in rare cases, mainly with hypo-pigmentation, the change may last longer or be permanent.

Blister

In some cases, a crust or blister may form, which may take five to ten days to heal.

Bruising

In some patients, a bruise may appear in the treated area. It may last anywhere between five to fifteen days.

Consent 3*

I understand that there is a possibility of rare side effects such as scarring and permanent discoloration, as well as short-term side effects such as redness, mild burning, bruising, blistering, and temporary discoloration of the skin.*

Consent 4*

I understand that I am to avoid active sun exposure for 2-4 weeks prior to treatment. I am not actively tanning outside or in a tanning facility at this time.*

Consent 5*

I will disclose a full and accurate personal medical history to include any and all information regarding medical conditions and my use of medications, drugs, herbs, vitamins, or other supplements of any kind. I understand that failure to do so may affect my treatment outcome.*

Consent 6*

I understand a patch test must be done before treatment and I must wait three to seven days to observe test before further treatment will be done.*

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.

Consent 7*

I understand that no specific guarantees are implied or made by this consent form.*

Consent 8*

I certify that I am a competent adult of at least 18 years of age. Or, that I am a minor under the age of 18 and understand the consent of my parent or legal guardian or person having legal custody of me will also be required prior to the time of treatment. This informed consent is freely and voluntarily executed and shall be binding upon my legal representatives, administrators, successors and assigns.*

Consent 9*

I have read and understand this agreement and all of my questions have been addressed and answered to my satisfaction. I hereby freely consent to the proposed treatment and agree to the terms of this agreement.*