Cosmetic Surgery Patient Form

Medical History - Please select if you have a history of the following:

Are you currently taking any medications? If yes, please list them below and provide the purpose and dosage.
Do you have any allergies? If yes, please list them below:
Body Composition*
Are you pregnant?

YesNo
Number of Children
Do you drink alcohol?

NeverOccasionallyDaily
Are you smoking?

NeverOccasionallyDaily
Are you taking any illicit drugs?

NeverOccasionallyDaily
Have you undergo any surgery before? If yes, please provide the surgery procedure's name, date, and reason.
Do you have a family history of any of the following? Please check the below, if none, then leave it blank.

HypertensionStrokeHeart DiseaseDiabetesCancerAnemiaOther
What cosmetic procedures are you interested in?*

Liposuction 360Breast AugmentationLiposuction 360 & BBLBreast Lift/ReductionHigh Definition Liposuction (Male/Female)Gynecomastia (Male Breast Reduction)Tummy TuckBody Contouring (Arms/Legs/Thighs)Blepharoplasty (Eyelid Surgery)Chin LiposuctionFacial RejuvenationRhinoplastyFace/Neck LiftOther
What type of consultation would you prefer?*

In-person ($250)Virtual (Facetime/Zoom) ($100)
Reference Photos

Face: Frontal, Right Profile, Left Profile, 3/4 Left, 3/4 Right

Breasts: Frontal, Right Profile, Left Profile

Abdomen/Waist/Hips/Buttocks: Frontal, Right Profile, Left Profile, 3/4 Left, 3/4 Right, Back
Please upload clinical photos

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Patient Information