Virtual Consultation
Intake Form
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Gender
*
Male
Female
Are you interested in being a PR client for marketing purposes?
Yes
No
Maybe
Back
Next
Do you have a history of breast feeding?
*
Yes
No
Have you delivered a child in the last 6 months?
*
Yes
No
Do you currently have any areas of concern with loose skin?
*
Yes
No
Height
*
Weight
*
Please identify your problem area(s)
Select as many areas as you would like. Also, please specify if your are interested in a fat transfer to the breast, buttocks, or hips.
Procedures
*
Arms
Armpits
Back / Bra Roll
Banana Rolls
Breasts
Buttocks
Chin / Jowls / Neck
Dorsocervical Fat Pad
Front Bra Roll
Gynecomastia / Chest
Inner Thighs
Knees
Love Handles (Flanks)
Lower Abdomen
Lower Back
Outer Thighs
Pubic
Upper Abdomen
Waist
Other
Are you interested in any of the following procedures?
Fat Transfer to Breast
Fat Transfer to Buttocks
Fat Transfer to Hips
Tummy Tuck
Mini Tummy Tuck
What were you planning on spending for a procedure?
*
Please Select
$0-$10,000
$10,000-$30,000
$30,000-$50,000
$50,000+
Are you interested in financing?
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Medical History
In order to expedite confirmation of your procedure candidacy, please provide your medical history.
Do you have any present illnesses?
*
Yes
No
Are you currently taking medication(s)?
*
Yes
No
Do you have any allergies?
*
Yes
No
Please check if you have any of the following current/past medical conditions:
*
Auto-Immune
Cardiac
Thyroid
Bariatric Surgery
Edema
Psoriasis
Anemia
Hernias
Irregular Heartbeat
PE
Hepatitis
Seizures
Easy Bruising
Hematology/Bleeding Disorder
HIV/AIDS
Dizziness
Psychiatric
Respiratory(Cough, Nose, & Throat)
Liver Disease (Ulcers, Chrohn's, IBS, Ulcerative Colitis, Diverticulitis)
Kidney Infection/Disease
Sleep Apnea (CPAP,BiPAP. Home Oxygen Use)
Increased Scarring (Keloid, Hyperpigmentation)
Rheumatoid Arthritis
Cancer
Hypertension
Diabetes(Type 1)
Endocrine Disorder
DVT
Blood Clotting
Intestinal
Neurological(Seizure, Stroke, Dizziness)
Asthma
Poor Healing
Organ Transplant (Donor Or Recipient)
Heart Attack
None of the above
Other
Have you had any blood work done within the last 3-6 months?
*
Yes
No
Have you had any medical, cosmetic, or elective procedures/treatments?
*
Yes
No
If yes, please specify
Social History
In order to provide you the safest care, please indicate the following
Tobacco/marijuana/hookah use:
*
Never
Former
Current User
Alcohol consumption
*
Never
Former
Current User
Back
Next
Save time and get a personalized quote by providing pictures of the problem areas you are interested in receiving
This is a secure portal provided to you to expedite your booking and to provide you with a personalized quote. Photos should be taken from just below your chin to your waist or knees, depending on the problem areas. The whole torso area should be visible with no undergarments, and the waist and hips may be visible if appropriate. Your hands and arms should be at your side but moved away from your body by several inches. Do not suck in the abdomen as this also creates an unnatural position. Inhale and exhale out to completely relax your abdomen. Keep the camera angle straight forward. Do not angle down or up as this will also create an unnatural position/view of the abdomen area. In addition to taking the photos sampled below, please take photos pinching the fat that you would like removed.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: