• Virtual Consultation

    Intake Form
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Gender*
  • Are you interested in being a PR client for marketing purposes?
  • Do you have a history of breast feeding?*
  • Have you delivered a child in the last 6 months?*
  • Do you currently have any areas of concern with loose skin?*

  • **

  • Please identify your problem area(s)

    Select as many areas as you would like. Also, please specify if your are interested in a fat transfer to the breast, buttocks, or hips.
  • Procedures*
  • Are you interested in any of the following procedures?
  • Are you interested in financing?*

  • Medical History

    In order to expedite confirmation of your procedure candidacy, please provide your medical history.
  • Do you have any present illnesses?*
  • Are you currently taking medication(s)?*
  • Do you have any allergies?*
  • Please check if you have any of the following current/past medical conditions:*
  • Have you had any blood work done within the last 3-6 months?*
  • Have you had any medical, cosmetic, or elective procedures/treatments?*

  • Social History

    In order to provide you the safest care, please indicate the following
  • Tobacco/marijuana/hookah use:*
  • Alcohol consumption*

  • Save time and get a personalized quote by providing pictures of the problem areas you are interested in receiving

    This is a secure portal provided to you to expedite your booking and to provide you with a personalized quote. Photos should be taken from just below your chin to your waist or knees, depending on the problem areas. The whole torso area should be visible with no undergarments, and the waist and hips may be visible if appropriate. Your hands and arms should be at your side but moved away from your body by several inches. Do not suck in the abdomen as this also creates an unnatural position. Inhale and exhale out to completely relax your abdomen. Keep the camera angle straight forward. Do not angle down or up as this will also create an unnatural position/view of the abdomen area.  In addition to taking the photos sampled below, please take photos pinching the fat that you would like removed.
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