"MyShape Lipo Consultation Request"
"It's as easy as 1,2,3! Simply, 1. Enter your information, 2. Take pictures on your phone, Upload and, 3. Schedule a time to discuss your options."
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Age
*
Height
*
Weight
*
List all medical conditions
*
List all medications you currently take and what they are for
*
Drug allergies
*
List any surgeries or procedures in the past 5 years. When were they?
*
Which sections of the body are you interested in treating?
*
Lower Body: Thighs
Midsection: Abdomen and Waist
Upper Body: Arms, Upper back, Chin
Are you interested in Fat Transfer?
*
Butt or BBL
Breasts
No Thanks
Do you have any special questions or concerns?
Where did you hear about us? Facebook, Google, Instagram, Friend/Family, Radio etc
*
Take pictures with your phone. You may use a mirror. Undergarments preferably. Please show your skin in the areas that you wish to treat. We require 4 FULL LENGTH photos from head to toe: Front, Sides and Back. Watch instruction video - https://youtu.be/ZMhoqj8yPwM
* If the pictures are not sufficient, we may request additional photos which will delay your consultation."
Upload your Front View
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Upload your Back View
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Upload your Left View
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Upload your Right View
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Consultation Date: Choose a time when our consultation specialist may call you to discuss your options. *If you are hoping to have a sooner date, we may be able to accommodate you, please call our office 702-8185476. *The consultation specialist will call you within approximately 30 minutes of your chosen date and time.
*
Message / Additional Info
Submit Form
Should be Empty: