Surgical & Permafill Services Consultation

Surgical & Permafill Services Consultation

Dr. Balgobin DOES NOT perform Tummy Tucks/Skin Removal or Breast Surgeries
Desired Treatment Location *

Minneapolis (Surgery & Permafill Offered)San Antonio (Surgery & Permafill Offered)Miami (Only Permafill Offered)
Procedure of Interest*
List Type of Surgery of Interest and/or Permanent Filler
Legal First & Last Name*

First NameLast Name
Date of Birth *

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender *

FemaleMaleNon-binaryTrans ManTrans Woman
Ethnicity *

African AmericanAsianCaucasian/WhiteHispanicMiddle EasternNative AmericanOther
Height (Feet)*
Height (Inches)*
Weight (Pounds) *
Heaviest Weight You've Ever Been *
Number of Children*
Are You Pregnant*

YesNo
Do You Smoke*

YesNo
List Past & Ongoing Medical History *
List Any/All Surgical History *
List All Medications*
List Prescription & OTC Vitamins/Supplements
List Any Medication Allergies*
How did you find us?*
Please provide photos of your front, sides and rear angles, clearly showing the area of concern so the Doctor can properly assess you. Nude images are prefered, can use emojis to cover areas you'd like to keep private or wear a bikini pulled up or down as long as the area of concern is clearly visible.

*If you would prefer to be seen in person, please upload any photo (can be of the floor) and request an in person consultation when scheduling your consult.
Photos:*
Photos:*
Photos:*
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