Surgical & Permafill Consultation

Surgical & Permafill Consultation

Dr. Balgobin DOES NOT perform Tummy Tucks/Skin Removal or Breast Surgeries
Minneapolis (Surgery & Permafill Offered)San Antonio (Surgery & 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
AT&TBell(CAN)BoostCingulairMetroMTS(CAN)Solo(CAN)SprintTelus(CAN)T MobileVerizonVirgin(CAN)Other
Email*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
FemaleMaleNon-binaryTrans ManTrans Woman
African AmericanAsianCaucasian/WhiteHispanicMiddle EasternNative AmericanOther
SingleMarried
Height (Feet)*
Height (Inches)*
Weight (Pounds) *
Heaviest Weight You've Ever Been *
Number of Children*
YesNo
YesNo
List Past & Ongoing Medical History *
List Any/All Surgical History(include years) *
List All Medications*
List Prescription & OTC Vitamins/Supplements
List Any Medication Allergies*
How did you find us?*
Please provide photos of your front, back and each side, clearly showing the area of concern so the Doctor can properly assess you. It is recommended you wear a swimsuit bottom or thong underwear, as long as the torso, buttocks/hips are visible and not hidden with any type of clothing. Nude images are OK with use of emojis to hide face, breasts & pubic area.

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