The Lipo Group Jot Form

  • General Information

  • Please note this e-consult may take up to 10 minutes! Thank you!

  • How did you first hear about us? / Como te enteraste de nosotras?*

  • Date of Birth / Fecha de nacimiento*
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  • What is your ideal procedure date / Cual es su fecha de procedimiento ideal?*
  • Please be aware that post-op recovery may take a few days to a week. It is suggested that you take off work to let your body recover. / Tenga en cuenta que la recuperacion postoperatoria puede llevar de unos dias a una semana. Se sugiere que se retire del trabajo para que su cuerpo se recupere.*

  • Health Information

  • Are you in good health? / Estas en buena salud?*
  • Are you pregnant? / Estas embarazada?*
  • If you pressed yes, how many? / Si presionaste si, cuantos?
  • Are you under the care of a physician? / Esta usted bajo el cuidado de un medico?
  • Have you been hospitalized or had a serious illness within the past 5 years? / Algun vez ha sido hospitalizado con una enfermedad grave en los ultimos 5 anos?*
  • Have you had prior cosmetic/plastic procedures? / Ha tenido procedimientos cosmeticos/plasticos previos?*
  • Have you experienced weight loss of 60 pounds or more within the past 2 years? / Ha experimentado perdida de peso de 60 libras o mas en los ultimos dos anos?*
  • Do you have, or have had, any of the following diseases/problems? / Tiene o ha tenido alguna de las siguientes enfermedades?*
  • Do you have allergies to any medications? / Tiene alguna alergia a los medicamentos?*
  • Do you have any food allergies? / Tiene alguna alergia a los alimentos?*
  • Are you currently, or have previously, have been prescribed any psychiatric medications? / Esta usted actualmente o ha sido prescrito previamente cualquier medicamento psiquiatrico?
  • Are you allergic or have you reacted adversely in any way to the following? / es alergico o ha reaccionado negativamente de alguna manera a lo siguiente*
  • Do you drink alcoholic beverages? / Tomas bebidas alcoholicas?*
  • Do you consume tobacco products? / Usted consume productos de tabaco?*
  • Are you taking any of the following? / Esta tomando cualquiera de los siguientes*
  • Do you have any disease, condition, or problem not listed that you think The Lipo Group should be aware of? / Tiene alguna enfermedad, condicio, o problema que usted piensa que el The Lipo Group debe ser consciente de?*

  • Finance

    If you are interested in our finance options, please contact our office. We are pleased to also offer in house financing. si usted esta interesado en nuestras opciones de finanzas, por favor pongase en contacto con nuestra oficina. nos complace ofrecer tambien financiacion en la casa.

  • Photos

    • Please make sure your photos are taken in a well lit area.
    • For privacy reasons, you do not have to show your face.
    • You may wear undergarments/bikinis in your photo.
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  • By clicking submit, I certify that all information is true and correct to the best of my knowledge and agree to The Lipo Group's privacy policy and to be contacted regarding our promotions.

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