Dr. Espinoza Consultation Request Form

Dr. Espinoza Consultation Request Form

Board Certified Plastic Surgeon
Name*

First NameLast Name
What is your sex?

FemaleMaleTransgender
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) 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?*

InstagramDr.Espinoza WebsiteGoogle/Internet SearchLA X 96.3 Radio w/DiosaFacebookRealSelf.comReferral/FriendOther
If Referral/Friend tell us their name, we'd love to thank them!
Cosmetic Surgery & Procedures
What procedure/s are you interested in?*

Rhinoplasty/Nose JobAbdominoplasty/Tummy TuckArm Lift/BrachioplastyBotoxBreast ImplantsBreast Implant ExchangeBreast LiftBreast ReductionLower Eyelid Surgery (eye bags) BlepharoplastyBlepharoplasty/Upper Eyelid SurgeryBrow LiftBBL/ Gluteal Fat TransferBuccal (Cheek) Fat RemovalFace LiftFacial Thread LiftOtoplasty (ear reduction )FillersH-D LiposculptingJ-Plasma Skin TighteningLiposuctionLiposuction of ArmsLiposuction of neck/jowl areas (Double Chin)Liposuction/360Neck LiftVirtue 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.
Have you ever had cosmetic surgery before?*

YesNo
Date of last surgery:
What was the procedure?
Are you transgender or in the process of transitioning?

YesNo
Are you a smoker? *

YesNoSocial
Your Health
Have you experienced any of these health conditions in the past or present?*

Hormone ImbalanceCancer / Systemic DiseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersHIV/AIDSLupusDepression/AnxietyHepatitisHeadaches / MigrainesOtherNone
Have you had a child in the past 12 months?*

YesNo
Are you currently breast feeding?*

YesNo
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 in person, 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. By signing below you also agree that the office of Dr. Espinoza may communicate with you via text messaging or email.*

I Agree
Should be Empty:

Dr. Espinoza Consultation Request Form

BODY MASS INDEX: BMI NOTICE

Cosmetic Surgery & Procedures

Your Health