Dr. Espinoza Consultation Request Form
Board Certified Plastic Surgeon
What is your sex?
What are your chosen pronouns?
Date of Birth
Height & Weight
BODY MASS INDEX: BMI NOTICE
Please be advised that if your BMI is over 32, Dr. Ronald Espinoza may suggests local anesthesia for your procedure. (Sedated but awake) Local anesthesia has made it possible to perform many surgical procedures quickly, with less preparation and a shorter recovery time while the patient is sedated but awake. This is for your safety. BMI is calculated by your height and weight. So please make sure your height and weight are correct.
District of Columbia
How did you hear about us?
LA X 96.3 Radio with Diosa
LA X 96.3 Radio with DJ Rey
If Referral/Friend tell us their name, we'd love to thank them!
Cosmetic Surgery & Procedures
What procedure/s are you interested in?
BBL/ Gluteal Fat Transfer
Buccal Fat Removal
J-Plasma Skin Tightening
Virtue RF Microneedling
What are your goals for surgery? For Example: To have a curvier body, bigger breast, get rid of my flabby stomach, look good in my clothes again.
What is the desired time frame for the procedure your interested in?
Less than 1 Month
1 to 3 Months
3 to 6 Months
6 or More Months
Have you ever had cosmetic surgery before?
Date of last surgery:
What was the procedure?
Any problems with Anesthesia? Local or General?
Are you transgender or in the process of transitioning?
Any known allergies?
Fragrances / Essential Oils
If Other, please specify
Are you a smoker?
Have you experienced any of these health conditions in the past or present?
Cancer / Systemic Disease
High Blood Pressure
Epilepsy / Seizure Disorder
Frequent Cold Sores
Headaches / Migraines
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)
Have you had a child in the past 12 months?
Current ages of all your children:
Delivery Type: Natural or C-Section:
Are you currently breast feeding?
Are you interested in financing?
Please upload photos of desired areas:
Please upload photos of desired areas. Must be a JPEG file.
Please upload photos of desired areas.
By submitting below, I am giving my consent to Dr.Espinoza for a pre-evaluation. Once I have been examined, I understand that I will be informed of any medical or cosmetic recommended procedures and/or treatments and given the option to accept or decline. I understand that my information and photos are protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and will not be shared. I also understand that the cost of the consultation is a non-refundable fee of $200.00 and maybe used towards my procedure/s.
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