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*
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?*

InstagramDr.Espinoza WebsiteGoogle/Internet SearchLA X 96.3 Radio w/DiosaFacebookMyrley Medical & Spa (Monica)Referral/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
Front – Upload a front-facing image*

Select An Image

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Left profile – Upload a left profile image*

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Right profile – Upload a right profile image*

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Back – Upload a back-facing image*

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.*

I Agree
Should be Empty:

Dr. Espinoza Consultation Request Form

BODY MASS INDEX: BMI NOTICE

Cosmetic Surgery & Procedures

Your Health