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Bringing Out The Beauty In You

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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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Permanent Makeup Intake Form

Permanent Makeup 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?*

Do you wear contacts?*

If so, they must be removed during an eyeliner procedure and should not be worn until the following day.

Do you have any tattoos?*

Have you ever had any Permanent Makeup procedures? If yes, please specify:*

write 'n/a' if not applicable.

Do you have any kinds of heart conditions? If yes, please specify:*

if none, write 'no'.

Are you a diabetic?*

Are you presently taking any medications, including any immunosuppressive, such as an anti-inflammatory, or steroids? If yes, which medications?*

If no, write 'no'

Are you able to take over-the-counter antihistamines?*

Are you allergic to topical antibiotic preparations (i.e. Polysporin, Bacitracin, Neosporin)?*

Are you allergic to any metals? (i.e. you can only wear 14K gold earrings)*

Do you have any other allergies? If yes, please specify:

Have you ever had a fever blister, cold sore (herpes), or canker sore? If yes, you must consult with and strictly follow your doctor’s instructions before contemplating any Permanent Makeup procedure.*

Are you using Retin-A, retinol, glycolic acids, or any exfoliating products?*

Are you taking Vitamin E or Aspirin regularly?*

Do you have a history of skin diseases or skin sensitivities? If yes, please specify:*

Check any of the following pertaining to you:

Contagious Diseases

Port Wine Hemangiomas

Hepatitis

Keloids

A.I.D.S.

Scleroderma

Respiratory Problems

Excessive Aspirin use

Glaucoma

Menstrual

Hemophilia

Pregnant

High Blood Pressure

Allergies

Diabetes

Hyperpigmentation

Lupus

Heart Problems (any)

Other

If other, please specify*

Have you had any type of surgery within the last 2 years? If yes, please explain:*

If none, write 'no'.

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.

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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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