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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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MLD Intake Form

MLD 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 2

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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?*

Please check any of the following conditions that apply to you:

Arthritis/Rheumatism

Asthma

Back Pain

Blood Clots

Bursitis

Cancer

Carpal Tunnel Syndrome

Diabetes

Eczema/Psoriasis

Fibromyalgia

Frequent Headaches

Heart Problems

Hepatitis

High/Low Blood Pressure

Infectious Disease

Immune Deficiency Disease

Joint Problems

Lymph Node Removal

Migraine Headaches

Nail/Foot Fungus

Open Wounds/Infections

Sciatica

Seasonal Allergies

Thyroid Condition

Torn Rotator Cuff

Varicose Veins

Please specify what type of Cancer:*

Do you have circulation problems or do you bruise easily?*

Do you have any allergies to lotions/oils, seaweed/iodine, or medications? If yes, please explain:*

if no, write 'no'.

Have you ever had a stroke or any other major injury? If yes, please explain:*

if no, write 'no'.

List all surgeries you have had within the last five years along with the dates of the surgeries*

write 'n/a' if not applicable.

Name and location of your surgeon(s):*

write 'n/a' if not applicable.

List any medications, herbals, and vitamins that you are currently taking:*

write 'n/a' if not applicable.

Do you have any other medical condition(s) that your technician/therapist should know about? If yes, please explain:*

if no, write 'no'

Have you had any lymph nodes removed? if yes, please explain where:*

if no, write 'no'

What are your expectations of the body treatment you will receive today?*

Where are your specific areas of complaint, pain or tension?*

write 'n/a' if not applicable.

Have you had a professional massage before?*

If yes, when?*

If yes, do you receive massages on a regular basis?*

Are you especially sensitive to touch/pressure in any specific areas? If yes, please explain:*

if no, write 'no'

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.

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Fields marked * are required

First Name* Last Name* Email* Phone* Procedure Interest

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Contact Us

Call: (419) 534-6552 Email Us Get Directions Request An Appointment

Associated with Craig Colville, MD and John F. Zavell, MD, FACS

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Bella Via Medical Spa is northwest Ohio's first and foremost medical spa, offering treatments including dermal fillers, laser hair removal, chemical peels, massage, and BOTOX® for Toledo, Holland, Sylvania, Sandusky, Bowling Green, and other Ohio and Michigan cities.

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