Client Information

calendar
calendar
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

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 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.
 
 *
 *
clear