The Lipo Group Jot Form

General Information
Please note this e-consult may take up to 10 minutes! Thank you!
Name/Nombre*

First NameMiddle NameLast Name
How did you first hear about us? / Como te enteraste de nosotras?*

InstagramFacebookGoogleWord of MouthOther
Date of Birth / Fecha de nacimiento*

MonthDayYear
Date
Gender / Genero*
Email / Correo*
example@example.com
Address / Addresion*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number / Numero de telefono*

Area CodePhone Number
Will you need finance options?*
What is your ideal procedure date / Cual es su fecha de procedimiento ideal?*

Within a monthWithin 3 months3 to 6 months6 to 12 months12+ months
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.*

YesNo
Tell us what procedure(s) you're interested in / Cual procedimiento o servicios uste estas interesado!*
Tell us what you would like to accomplish through these procedures! Diaganos lo que le gustaria lograr a traves de estos procedimientos!
Health Information
Height / Estatura*
Weight / El peso *
What is your BMI? / Cual es tu BMI?
Are you in good health? / Estas en buena salud?*

YesNo
If you pressed no above, please explain why / Si no presiono nada de arriba, por favor explique por que *
Are you pregnant? / Estas embarazada?*

YesNo
Do you have children? / Tienes hijos?
If you pressed yes, how many? / Si presionaste si, cuantos?

1234+
What is the age of your youngest child? / Cual es la edad de su hijo menor?
Are you under the care of a physician? / Esta usted bajo el cuidado de un medico?

YesNo
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?*

YesNo
If you pressed yes above, please explain why / Si usted presiono si arriba, por favor explique por que*
Have you had prior cosmetic/plastic procedures? / Ha tenido procedimientos cosmeticos/plasticos previos?*

YesNo
If you pressed yes above, please explain which procedures / Si presiono si arriba, explique que procedimientos*
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?*

YesNo
Do you have, or have had, any of the following diseases/problems? / Tiene o ha tenido alguna de las siguientes enfermedades?*

Active Cancer or LeukemiaBleeding DisorderChronic Viral InfectionDiabetesHeart AttackHepatitis or other liver diseasesHIV/AIDSLupus, or LCERheumatic FeverSeizures or Neurological DisordersSickle Cell DiseaseStrokeI do not have, or have not had, any of the diseases mentioned above
Do you have allergies to any medications? / Tiene alguna alergia a los medicamentos?*

YesNo
Please list all medication(s) you may be allergic to / Por favor enumere todos los medicamentos que usted puede ser alergico a*
Do you have any food allergies? / Tiene alguna alergia a los alimentos?*

YesNo
Please list all food(s) you may be allergic to / Por favor enumere todos los alimentos que usted puede ser alergico a *
Are you currently, or have previously, have been prescribed any psychiatric medications? / Esta usted actualmente o ha sido prescrito previamente cualquier medicamento psiquiatrico?

YesNo
If you pressed yes above, please explain / Si usted presiono si arriba por favor explique
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*

Local anesthesiaPenicillin or other antibioticsSulfa drugsBarbiturates, sedatives, or sleeping pillsAspirinIodineNone of the above
Do you drink alcoholic beverages? / Tomas bebidas alcoholicas?*

AlwaysSociallySometimesNever
Do you consume tobacco products? / Usted consume productos de tabaco?*

DailySociallySometimesNever
Are you taking any drug or medications, prescription or non prescription? / Esta tomado algun medicamento o medicamento recetado o sin receta *
Are you taking any of the following? / Esta tomando cualquiera de los siguientes*

AntibioticsAnticoagulants or Blood thinnersNon Prescription Medicals (Herbal Remedies/Weight Loss/Vitamins)High Blood Pressure MedicationsCortisone (steroids)TranquilizersAspirinInsulin or TolbutamideDigitalisNitroglycerinNone of above
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?*

YesNo
If so, please explain / Si es asi, por favor explique *
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.
Front View Shot*

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Left Side View*

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Right Side View*

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Rear View Shot*

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General Information

Health Information

Finance

Photos