Client Information

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calendar calendar
Gender *

Guardian

Past Medical History

Allergies and Medications

Do you have any known allergies? *
High Blood Pressure *
Diabetes *
Thyroid Disease *
Bleeding Disorder *
Blood Clots *
Lung Disease *
Hepatitis *
Anemia *
Skin Disease *
Liver Disease *
Shortness of Breath *
Tuberculosis *
History of Seizures *
Kidney Disease *
Heart Problems *
Herpes I or II *
HIV *
Psychiatric Illness *
Keloid Scarring *
Dizziness/Fainting *
Vascular Disease *
Asthma *
Hernia/Umbilical *
Other *
Please indicate if one of these options apply to you.
Are you on any of the following medications? If not, please select "None." *

Reasons for Visit

What are your interests? *

Liposuction

If you chose "Liposuction", which areas are you interested in?
Face
Abdomen
Core
Arms and Legs

Should we give you a call about our Weight Loss Program?

Contact by Email

My Daily Questions (Be Sure to "Save" your form when Complete)
 Enter as much as you want to ask for "Questions"
Daily Questions
Daily Questions
Daily Questions
 *

OFFICE USE

Minimal Deposit is required for scheduling surgery ($500) 
CANCELLATION POLICY: I understand that if, for any reason, I must cancel my appointment on the scheduled appointment date, I am subject to forfeiting half of the total procedure cost, which will include the $500 security deposit, for the procedure. I also understand that if I must cancel my appointment 2 weeks prior to the scheduled appointment, I will be compensated my procedure cost in full, but will forfeit the $500
security deposit.
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Action Plan for the Patient