Consultation Form | Body contouring

Patient Information

Body contouring Procedures

Please mark which procedure(s) you are interested in. *
Optional- To help us better understand what your goals are we have listed common desires
 Excess skinStretch marksMuscle repairOther:
Reasons why you want a Tummy Tuck Procedure
 I work out but this area won't go awayI would like this area to be more in proportion to the rest of my shapeI would like to have better curvesI am looking to lose as many inches as possibleOther:
Reasons why you want a Liposuction Procedure
 I want a "bubble butt"My main concern is the lower part of my buttocksI want the shape changedI like my shape I just want more projectionOther:
Reasons why you want a Buttock Enhancement Procedure
Please attach your photos below for the sugeons review. It is very important the surgeon has clear photos of the areas in order to give you an accurate consultation. Please review the sample pictures so you know what views we need. you can wear undergarments however please make sure they are not tight or cover the areas we need to review. File Size: 1 MB Per Picture

 

 

 

 
Have you had a C section?
Do you plan on having more children?
Has your weight been stable for 6 months or more?
Compression Garments: We will need some measurements to provide you with the right garments after your surgery.

Others Question & Medical History

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Medical History

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Do you have any allergies to medications?
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Do you currently have any problems in the following areas?
                                                                         If yes, please explain:
Do you have any allergies to medications?
 
General / Constitutional (fever, weight loss, other)
 
Do you have any allergies to medications?
 
Ears, Nose, and Throat (cold, sinus, chronic cough)
 
Cardiovascular (heart, vessels, etc.)
 
Respiratory (asthma, emphysema, etc.)
 
Gastrointestinal (ulcers, intestinal disease, etc.)
 
Genital, Kidney, Bladder
 
Skin (rosacea, skin cancer, psoriasis, etc.)
 
Neurological (MS, stroke, seizures, etc.)
 
Psychiatric (anxiety, depression, etc.)
 
Endocrine (diabetes, thyroid, etc.)
 
Blood / Lymph (bleeding disorder, high cholesterol, anemia, etc.)
 
Allergic / Immunologic (lupus, hay fever, rheumatoid arthritis, etc.)
 

Social History

Do you smoke?
Do you drink alcohol?
Do you exercise?