Assessment Form 2025

1
Name* This field is required.
First Name
Last Name
2
What would you like to be identified as?* This field is required.
Female
Male
Non-binary
3
If answered non-binary please let us know what would you like to be identified as:
4
Email* This field is required.
example@example.com
5
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Phone Number* This field is required.
Area Code
Phone Number
7
Date of Birth* This field is required.
Date
Day
Month
Year
8
Weight* This field is required.In Kilograms
9
Height* This field is required.In Centimeters
10
Have you or any of your family had problems with to anaesthesia?* This field is required.
YESNO
11
If answered yes to problems with anaesthesia please provide further details:
Huge
Large
Normal
Small
Ok
Ok
12
Are you a smoker?* This field is required.
YESNO
13
How much do you smoke?
1-5 per day
6 - 10 per day
11-15 per day
16-20 per day
Over 20 per dayl
Only on social occasions
14
Do you use or take illegal substances?* This field is required.
YESNO
15
If answered yes, please provide further details
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Small
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Ok
16
Do you use or take herbal supplements?* This field is required.
YESNO
17
If answered yes, please provide further details
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Small
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Ok
18
Do you use a gym / sauna / steam room* This field is required.
YESNO
19
If answered yes, please provide further detailsHow often, how long
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Ok
20
Have you been pregnant or given birth?* This field is required.
YESNO
21
If answered yes, please provide further details. Please enter the dates of your pregancy / childbirths - including type of delivery...
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Ok
22
Are you currently breastfeeding?* This field is required.
YESNO
23
Is there a chance you could be pregnant?* This field is required.
YESNO
24
If answered yes, please provide further details...
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Ok
25
Are you currently taking birth control?* This field is required.
YESNO
26
If answered yes, please provide further details...
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Small
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Ok
27
Have you ever lost excess weight?* This field is required.
YESNO
28
If answered yes, please provide further details...
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Small
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Ok
29
Do you have any allergies?* This field is required.
YESNO
30
If answered yes, please provide further details...
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Small
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Ok
31
Have you ever had an allergic reaction?* This field is required.
YESNO
32
If answered yes, please provide further details...
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Small
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Ok
33
Have you contracted Covid 19?* This field is required.
YESNO
34
If answered yes, please provide further details...
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Small
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Ok
35
Did you receive your covid vaccination or plan to?* This field is required.
YESNO
36
If answered yes, please provide further details...
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Ok
37
Do you suffer from or have you ever suffered from the following... Chest Pains / Tightness or Angina, Previous Rheumatic Fever, Previous Heart Attack, Palpitations, Heart Murmur, Heart Disease, High Blood Pressure, Low Blood Pressure, Artificial Heart Valve or Pacemaker, Hiatus Hernia / Heartburn / Indigestion, Anemia, Diabetes – Oral Medication, Diabetes – Insulin-Dependent, Kidney Disease, Rheumatoid Arthritis, Shortness of breath, Asthma, Emphysema or Bronchitis, Tuberculosis, Stroke or seizures, Jaundice or Hepatitis, Thyroid Disease, Previous DVT or Lung Embolus, Bleeding or clotting disorder, Sickle Cell, Cancer, Skin Desease, Ulcers, Gastritis, Obstructive Sleep Apnoea, Persistent Cough, Motion Sickness, Depression, Hepatitis, HIV, Blood Transfusion* This field is required.
Chest Pains / Tightness or Angina
Previous Rheumatic Fever,
Previous Heart Attack
Palpitations
Heart Murmur
Low Blood Pressure
Heart Disease
High Blood Pressure
Artificial Heart Valve or Pacemaker
Hiatus Hernia / Heartburn / Indigestion
Anemia
Diabetes – Oral Medication
Diabetes – Insulin-Dependent
Kidney Disease
Rheumatoid Arthritis
Shortness of breath
Asthma
Emphysema or Bronchitis
Tuberculosis
Stroke or seizures
Jaundice or Hepatitis
Previous DVT or Lung Embolus
Bleeding or clotting disorder
Sickle Cell
Thyroid Disease
Cancer
Skin Diseases
Ulcers or Gastritis
Obstructive Sleep Apnoea
Persistent Cough
Motion Sickness
Depression
Hepatitis
HIV
Blood Transfusion
NONE
38
If answered yes to any of these, please provide further details...* This field is required.
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Ok
39
Are you taking or have been prescribed any medication?* This field is required.
YESNO
40
If answered yes to any of these, please provide further details...
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Ok
41
Do you have any family medical history? * This field is required.
YESNO
42
If answered yes to family medical history, please provide further details...
43
Is your interest in Surgical or Non-surgical prodecures?* This field is required.
44
What is the treatment / procedure you are interested in and what would you like to achieve?* This field is required.
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45
Which location are you planning to have your procedures?* This field is required.
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Ok
46
When are you planning to undergo your procedures?* This field is required.
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47
Do you have any upcoming surgergies / procedures / treatments?* This field is required.
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48
Have you ever had surgery before?* This field is required.
YESNO
49
If answered Yes please give further details:Date and type of each procedure. Any complications or problems since? Any further medical care and when.
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50
Do you plan to have a surgical BBL (liposuction and fat transfer) in the future?* This field is required.
YESNO
51
If answered Yes please give further details:For those that plan to have a surgical BBL in the future, a non surgical BBL is not recommended.
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Ok
52
Do you have Breast Implants?* This field is required.Please give details such as brand, size and type of implant.
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Small
Ok
Ok
53
Do you have Buttock or any other Implants?* This field is required.Please give details such as brand, size and type of implant.
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Small
Ok
Ok
54
Were you referred to Elite by someone?* This field is required.Please give the name of the person that referred you.
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Ok
55
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56
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57
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58
Please read the Terms and Conditions
59
I have read and understood the terms & conditions and the privacy policy - Signature required* This field is required.
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60
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