Dr. Espinoza Consultation Request Form

Dr. Espinoza Consultation Request Form

Board Certified Plastic Surgeon
Name

First NameLast Name
What is your sex?
Date of Birth
MM/DD/YYYY
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) BMI is calculated by your height and weight. So please make sure your height and weight are correct.
Phone Number
E-mail
Address

Street Address

Apt/Floor

CityState

Zip Code
How did you hear about us?

Other
If Referral/Friend tell us their name, we'd love to thank them!
Cosmetic Surgery & Procedures
What procedure/s are you interested in?
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.
Have you ever had cosmetic surgery before?
Date of last surgery:
What was the procedure?
Are you transgender or in the process of transitioning?
Are you a smoker?
Your Health
Have you experienced any of these health conditions in the past or present?
Have you had a child in the past 12 months?
Are you currently breast feeding?
Tips for taking Photos:

Please stand against a solid background wall or door with plenty of light.(no dark images please)

Camera should focus on the area of the body you are concerned about.

Self-timers work well if you are alone and can't have someone take a photo of you.

For body images please take all four sides, front, both right and left sides as well as back. Do NOT send NUDE photos, you may keep your undergarments on. NO PANTS, LEGGINGS or other CLOTHING.

For Breast: NO BRA and please CROP OUT your face.

For Arms: Raise your arms to a T shape front and back only needed.

For Face: Front, Right, Left profiles and looking up so we can see the size of the nostrils if it's for a rhinoplasty (nose job) request.
Front – Upload a front- image

Select An Image

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Left profile – Upload a left side image

Select An Image

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Right profile – Upload a right side image

Select An Image

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Back/Buttocks – Upload a back image if you are requesting a BBL.

Select An Image

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Back – Upload a back image if you want a procedure done on your back such as Liposuction.

Select An Image

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Nostrils: For RHINOPLASTY Patients ONLY. With your chin upwards so we can see both notrils evenly.

Select An Image

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Authorization & Consent
I agree to receive marketing communications via text message and email from Dr. Ronald Espinoza’s office. I understand that message and data rates may apply, and that I can revoke this permission at any time. By submitting this form, I also consent to a preliminary evaluation by Dr. Espinoza’s office. Once I have been examined in person, I will be informed of any recommended medical or cosmetic procedures or treatments, and I will have the option to accept or decline them. 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.
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Dr. Espinoza Consultation Request Form

BODY MASS INDEX: BMI NOTICE

Cosmetic Surgery & Procedures

Your Health