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English (US)
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Name Surname
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Name
Surname
Contact number
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E-Mail Address
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Gender
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Male
Female
Rather not say
Other
Gender
Age
*
Weight
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Height
*
How did you reach us
*
instagram
Facebook
Google
Other
Which procedure are you in interested in having? (you can select more than one)
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Rhinoplasty/Nose Job
Liposuction
Mommy Makeover
Breast Augmentation
Breast Lift
Labiaplasty
Arm Lift
Thigh Lift
Brazilian Butt Lift / Fat Transfer
Eyelid Surgery
Thread Lift
Other
Do you have/had any of the following diseases and/or health conditions?
*
Active Cancer or Leukemia
Bleeding Disorder
Chronic Viral Infection
Diabetes
Heart Attack / Myocardial Infarction
Hepatitis or other liver diseases
HIV
Lupus
Rheumatic Fever
Seizures or Epilepsy
Sickle Cell Disease
Stroke
Pacemaker
I do not have and have not had any of the diseases or problems listed above.
Other; Not listed
Have you ever had or do you have a history of hypertension (high blood pressure)?
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Yes
No
If so, is it controlled and/or being treated by a physician?
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Yes
No
Are you allergic or have you reacted adversely in any way to the following?
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Lidocaine
Penicillin or Other Antibiotics
Sulfa drugs
Barbiturates Sedatives or Sleeping Pills
Aspirin
Iodine
None of the substances listed above apply
Have you previously undergone bariatric surgery or experienced weight loss over 80 pounds (35 kg)?
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Yes
No
Can you text in english with our patient manager?
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Yes
No
Preferred languages?
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🇬🇧
🇫🇷
🇩🇪
🇪🇸
🇮🇹
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Staff
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I am over 18
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