Doctors in the Sun Inc.

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Place of Birth ?

Country of Residency ?

What is your occupation?

What is your current age?

What is your height ?

What is your weight ?

What was your maximum weight?

Do you Smoke?

NoYes

If Yes, How many cigarettes do you some a day?

Do you participate in any sport?

YesNo

If so, which sport(s)?

Do you have any disease or medical condition?

YesNo

If Yes, Please list all.

Do you currently take any kind of hormonal treatments, pills or pads?

YesNo

Do you take any prescription drug(s)?

YesNo

If YES, list with dosages

Do you follow any type of special diet?

VeganVegetarianKetoOther

Do you consume any of the following?

Vitamin EGarlicCurcuma

Do you have allergies?

YesNo

If yes, please tell us what your allergies are

Do you have any type of abnormal scaring such as keloid, hypertrophic, etc?

YesNo

If "yes" please explain

Have you had any kind of aesthetic treatments in the abdominal wall such as mesotherapy, cavitation. Is so, please tell us which treatment, how many and how long ago.

If YES please tell us which treatment and how many treatments

If you're a woman, have you had children ?

YesNo

If yes, how many children have you had, were they vaginal deliveries or C-section?

Have you had previous surgeries? If you please tell us what surgery you've had and how long ago. Thanks

Have you had any treatments in the face such as fillers, radiofrequency, mesotherapy, enzymes, etc?

Have you ever used botulinum toxin?

It's extremely important that we have a full understanding of your health and your medical history. PLEASE be sure to answer ALL questions. If there is any condition that is not listed here please take a few minutes and detail your situation.

Following a review of your information if the doctor feels you're a likely candidate for plastic surgery you'll be asked to provide pictures of the area you wish to improve. We will provide exact instructions and your photos will be seen by only the surgeon. Your confidentiality is assured