About
Medical Spa
- Skin Rejuvenation
- Injections
  - BOTOX® & Neuromodulators
  - Dermal Fillers
- Lasers & Energy
  - Laser Hair Removal
  - Sofwave™ Skin Tightening
Day Spa
Shop
Resources
- Rewards Programs
- New Client Forms
Contact
Blog

Bringing Out The Beauty In You

Model

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.

Home
Resources
New Client Forms
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

50%

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.

Contact Us

Fields marked * are required

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

I accept the Terms of Use Terms & Conditions*

By checking the box on the contact form, you agree to the Terms of Use listed here: Communications through our website or via email are not encrypted and are not necessarily secure. Use of the internet or email is for your convenience only, and by using them, you assume the risk of unauthorized use. By checking this box you hereby agree to hold Bella Via Medical Spa, its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties.

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Contact Us

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

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

New Client Forms
Privacy Policy
Site Map

Find us on:

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.

Medical Website Design & Marketing by Etna Interactive

Contact

Home
About
Medical Spa
Day Spa
Shop
Resources
Contact
Blog