"MyShape Lipo Consultation Request"

"Paid 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 NameLast 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?*
What Section of the body are you interested in addressing?*

Lower Body: ThighsMidsection: Abdomen and WaistUpper Body: Arms, Upper Back and Chin
Would you like Fat Transfer*

Butt, BBLBreastsNo 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*

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Upload your Back View*

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Upload your Left View*

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Upload your Right View*

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Message / Additional Info
Consultation Date: Choose a date and time to for your call to discuss your options. If you have any questions or concerns please call 702-818-5476. * will call you within approximately 30 minutes of your chosen time. $100 CONSULTATION FEE IS NOT REFUNDABLE*

My Products

Body Shape AnalysisYour photos will be reviewed by our Liposuction Specialist and you will be called at the specified time. A quote will be given once the plan is determined. *This fee is non-refundable.

$100.00

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

"Paid Consultation Request"

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