Name
Phone Number
Email
Address
City
Postal / Zip Code
State / Province
Date Of Birth
Age
Weight
Height
4
4'1
4'2
4'3
4'4
4'5
4'6
4'7
4'8
4'9
5
5'1
5'2
5'3
5'4
5'5
5'6
5'7
5'8
5'9
6
6'1
6'2
6'3
6'4
6'5
6'6
6'7
6'8
6'9
7
Marital Status
Single
Married
Divorced
Occupation
Previous Surgeries?
Other Allergies please list
Are you in good health?
Yes
No
Are you under medical treatment now?
Yes
No
If yes, which treatments:
Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?
Yes
No
If yes, please explain:
Have you ever had any complication after undergoing general anesthesia in the past?
Yes
No
If yes, please explain:
Are you taking any medications including non- prescription medicine?
Yes
No
If yes, please which medications are they:
Are you under any type of pain management?
Yes
No
If yes, please which medications are they:
Have you ever taken or are currently taking any weight loss medication?
Yes
No
Do you use tobacco/nicotine products?
Yes
No
Are you exposed to second hand smoking?
Yes
No
How often do you consume alcohol?
Yes
No
Do you use or do you have history of using recreational drugs?
Yes
No
Occasionally
Number Of Children
When was your last delivery
Are you pregnant or think you may be pregnant?
Yes
No
If no, when was the last time you breastfeed (month/year)
Are you under any type of birth control treatment? ( Oral contraceptives, Nuva ring, IUD, Arm implant, Depo shot, etc.)
Yes
No
Have you had any abortion/miscarriage or pregnancy in the last 8 weeks? *
Yes
No
List other conditions:
Have you ever had any operations to your head, eyes, ears or spine? *
Yes
No
Do you have any surgical hardware or material placed in any part of your body? *
Yes
No
Any Medical conditions we should be aware of?
Have you had abnormal bleeding?
Yes
No
Have you had any foreign substance injected in your buttocks area? *
Yes
No
Take a front picture of the body area you'd like to enhance, make sure to not include your face. ( Front View )
Take a side picture of the body area you'd like to enhance, make sure to not include your face. ( Right Side View )
Take a side picture of the body area you'd like to enhance, make sure to not include your face. ( Left Side View )
Take a photo of the area of your back you would like to improve, make sure not to include your face. (View from the back)
Send
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