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Hello!
We are so excited you’re here! Congratulations on taking your first steps to becoming your best version! Answer the questions within and we’ll be right with you!
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1
Name
First Name
Last Name
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2
Mobile Number
Please enter a valid phone number.
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3
Email
example@example.com
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4
What coordinator is assisting you?
Please Select
Yesi
Goldi
Lexi
Apryl
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Please Select
Yesi
Goldi
Lexi
Apryl
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5
Instagram
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6
Which type of procedures / services are you seeking?
Plastic Surgery
Bariatric Surgery
Cosmetic Dentistry
Recovery House
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7
Desired Date
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Date
Month
Day
Year
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8
Gender
Female
Male
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9
Date of Birth
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10
Age
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11
Height
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12
Weight in LBS
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13
Number of Pregnancies
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14
Date of Last Pregnancy
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15
Known Allergies?
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16
Known Medical Conditions
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17
List Previous Surgeries & Date
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18
Do You Smoke
Cigarettes, Hookah, Marijuana, Vape
Yes
No
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19
Do You Drink Alcohol
YES
NO
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20
Do You Use Recreational Drugs?
YES
NO
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21
Do You Suffer From Hyper/Hypotension?
YES
NO
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22
Do You Suffer From Sickle Cell Disease / Trait Carrier ?
YES
NO
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23
Do You Suffer From Díabetes ?
YES
NO
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24
Do You Suffer From Thyroid Disease ?
YES
NO
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25
Do You Suffer From Asthma?
YES
NO
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26
Do You Suffer From Anemia?
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NO
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27
Do You Have a Cancer History?
YES
NO
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28
Are you HIV / AIDS Positive?
YES
NO
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29
Have you had COVID-19?
Yes
No
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30
Would you like Recovery Home (care, stay, meals, massages and transportation) included in your quote?
Yes
No
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31
Desired Procedures
Lipo 360 & BBL
Lipo Tummytuck & BBL
Mommy make over
Breast Only
Thigh lift
Arm lift
Back lift
Chin lipo
Blepharoplasty (eyelid surgery)
Fillers / Botox
Smile Design
Teeth Whitening
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32
What Surgeon(s) are you interested in?
Please Select
Dra. Corona
Dra. Baez
Dr. Pedro Chalas ( Dr. Pencil)
Dr. Paul Feliz
Dr. Felix Almanzar
Dental
Send me quotes from surgeons based on my needs
Please Select
Please Select
Dra. Corona
Dra. Baez
Dr. Pedro Chalas ( Dr. Pencil)
Dr. Paul Feliz
Dr. Felix Almanzar
Dental
Send me quotes from surgeons based on my needs
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33
File Upload
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
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File Upload
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File Upload
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File Upload
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: 10.6MB
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