Intake Form

Please allow 24-48 hr.'s for a response

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Full Name

Date of Birth

Cell Number

Occupation

Address (Full address) City, Zip

Medical Information

Are you currently under Medical Care? Required

Yes

If yes, please discribe in details

What is your current BMI?

What is your height & weight?

Do you have any underlying medical condition? Such as diabetes, highblood pressure etc

Are you currently taking any medications?

Do you smoke or consume alcohol? if so, how frequently?

What Procedure(s) are you considering?

Whose your plastic surgeon? is this your first round?

Surgery Date & Pre-op Date

What is the facility name where you are having surgery?

What service(s) are you wanting us to provide for you?

Have you researched the recovery process for the procedure(s) you're considering? If so what are your expectations?

Please tell us who reffered you ( If a person, Full Name) or social media platform