Quote and Availability Inquiry

Quote and Availability Inquiry
Hello and thank you for your interest in Sei Bello Cosmetic Concierge!

Please take a moment to complete the inquiry form thoroughly and accurately. The information provided allows us to confirm availability, determine whether we are able to accommodate your needs, and provide accurate pricing.

Please note the following eligibility requirements:
- In accordance with Florida regulations governing our service model, Sei Bello maintains a mamimum 2 client care ratio.
- Clients may have private health insurance, Marketplace health insurance, or be uninsured/selfpay.
- Unfortunately, clients enrolled in state Medicaid plans cannot be accepted for services.
Once your inquiry has been rviewed. we will follow up regarding availability and the appropriate service options for your requested dates.

We look forward to being part of your surgical journey and providing the personalized care and support you deserve.

Sei Bello Cosmetic Concierge

Recover Beautifully
Legal Name (as indicated on your ID)

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
What is your gender identity?
Surgery Type
Surgeon
Surgery Center
What is your daily budget for recovery home assistance (for example service starts at $225 per night)
Pre-op Date (DOUBLE CHECK FOR ACCURACY)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Surgery Date (DOUBLE CHECK FOR ACCURACY)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Which level of care are you interested in
Desired check in date (must check in at minimum (1) day before your scheduled surgery DOUBLE CHECK FOR ACCURACY)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Desired check out date (3-night minimum required DOUBLE CHECK FOR ACCURACY)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
How did you hear about us
What is your Facebook name
What is your Instagram name
Will you be traveling alone
If traveling with a companion, is your companion a Male **Companion is considered as a friend or family member who is NOT having surgery.**
Is this your first elective surgery? If not, what surgeries have you had?
Have you undergone weight loss surgery? If yes, when?
Have you ever tested positive for HIV or any other communicable diseases? If so, please disclose to ensure the necessary precautions are taken for the safety of yourself and our staff. (Answering yes does not affect your ability to book.)
Do you have a past history (personally or genetically) that may be of a concern and or deem you "High Risk" for surgery? (ie: Heart Disease, Heart Attack, Blood Clots, Asthma, Sleep Apnea etc)
What type of health insurance do you have? Please note: Clients with State medicaid cannot be accepted.
What is your current BMI?
Do you know the BMI requirement of your surgeon? If yes, what is it?
What is your current height and weight? Please answer both parts of the question.
Do you have allergies?
List allergies and or food restrictions
Please list dietary accommodations needed during your stay
Do you have a clear understanding of what post op assistance entails? Please provide a brief description of the services you expect to receive.
Do you wish to receive IV therapy following surgery? If yes, which option? **IV therapy is an add on service at your expense and is administered by a 3rd party vendor**
Select any add-on options you'd like to add to your package.
What payment method do you intend to use upon booking?
I have reviewed my answers for accuracy, and I understand that submitting this inquiry Does Not guarantee service.
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