Health & Consultation Package
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of birth?
*
Height?
*
Weight in pounds or kilos?
*
What is your BMI?
Please use a BMI Calculator; copy and paste the link below to a browser.
https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm
Gender
*
female
male
transgender-born female
transgender-born male
How many pregnancies?
*
Number of children?
*
What procedures are you interested in?
*
List of surgeries?
*
Date you'd like to travel for you Health and Consultation Trip?
*
-
Month
-
Day
Year
Date
Date you are looking to have surgery?
*
-
Month
-
Day
Year
Date
Surgeons interested in?
*
Have you had biogel or biopolymer injections?
*
Yes
No
Have you had sculptra injections?
*
Yes
No
Have you had any issues with anesthesia?
*
Yes
No
Do you smoke?
*
Yes
No
sometimes
Do you drink?
*
Yes
No
sometimes
Do you use any recreational drugs ever?
*
Yes
No
Any type of addiction?
*
Yes
No
Are you under a doctor's care?
*
Yes
No
High/low blood pressure?
*
Yes- high
Yes-low
No
Seizures?
*
Yes
No
Asthma?
*
Yes
No
Leukemia?
*
Yes
No
Diabetes?
*
Yes
No
Kidney disease?
*
Yes
No
AIDS/HIV?
*
Yes
No
Sexually transmitted disease?
*
Yes
No
Thyroid disorder?
*
Yes
No
Adrenal gland tumor?
*
Yes
No
rheumatoid arthritis?
*
Yes
No
sickle cell trait/disease?
*
Yes-trait
Yes-disease
No
Heart disease?
*
Yes
No
Heart murmur?
*
Yes
No
Cardiac pacemaker
*
Yes
No
Heart attack
*
Yes
No
Recent weight loss
*
Yes
No
I understand the information above is correct
*
Submit
Submit
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