Client Intake Form

Client Information

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Gender *
Have you been contacted or talked to someone in our office, either via email of phone? If so please choose a name below. *
Whats your availability for a consultation? *
What location are you inquiring about? *
Have you had other consultations? *

Guardian

Allergies

Do you have any known allergies? *

Medical Conditions

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.
Please mark if you are using any non-medical drugs. The various classes of drugs may include: *
 
Are you on any of the following medications? If not, please select "None." *

Past Surgical History

Reason(s) 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

Question You Would Like to Bring Up During Consultation (Optional)
 Patient Questions and Concerns
Question/Comment
Question/Comment
Question/Comment
 *

OFFICE USE

Minimal Deposit is required for scheduling surgery if you decide to move forward and book a date or secure price. The minimum deposit is ($500) this will be applied to the surgery price. 

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 I must
 give 2 weeks notice if I need to cancel my scheduled appointment. Frailer to do so will subject in loosing the amount paid.
 
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