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 so we may provide you with a price quote for your recovery needs. We look forward to assisting you on your journey!
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
What is your Facebook name?
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What is your Instagram name?
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Surgery Type
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Surgeon and Surgery Center
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How did you hear about us?
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What is the name of the package or sale you are interested in?
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What is your gender identity?
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Female
Male
Transgender Female
Transgender Male
Nonbinary/Nongender/Nonconforming
Will you be traveling alone?
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Yes
No
If traveling with a companion, is your companion a Male? **Companion is considered as a friend or family member who is NOT having surgery.**
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Yes
No
What is your daily budget for recovery home assistance (for example $200 per night)?
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Pre-op Date (DOUBLE CHECK FOR ACCURACY)
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-
Month
-
Day
Year
Date
Surgery Date (DOUBLE CHECK FOR ACCURACY)
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Month
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Day
Year
Date
Is this your first elective surgery? If not, what surgeries have you had?
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Have you undergone weight loss surgery? If yes, when?
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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.)
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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)
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What is your current BMI?
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Do you know the BMI requirement of your surgeon? If yes, what is it?
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What is your current height and weight? Please answer both parts of the question.
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Desired check in date (DOUBLE CHECK FOR ACCURACY)
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Month
-
Day
Year
Date
Desired check out date (DOUBLE CHECK FOR ACCURACY)
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Month
-
Day
Year
Date
Do you have allergies?
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Environmental
Medication
Food
Other
List allergies and or food restrictions
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Please list dietary accommodations needed during your stay
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Gluten Free
Pescatarian
Vegan
Vegetarian
Lactose Intolerant
No accommodations needed
Do you have a clear understanding of what post op assistance entails? Please provide a brief description of the services you expect to receive.
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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**
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Yes
No
Iv only $260
Iv w/iron $280
Select any add-on options you'd like to add to your package.
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Iaso Detox Tea 5 Day Supply
Stage 1 Garment
Stage 2 Garment
None
What payment method do you intend to use upon booking?
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Credit/Debit
Cashapp
ApplePay
Buy Now Pay Later (After Pay, Affirm, Klarna)
Chime
Zelle
Venmo
I have reviewed my answers for accuracy, and I understand that submitting this inquiry Does Not guarantee service.
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Yes
No
Submit
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