Consultation Intake Form

* Please note: This form should take approximately 5-10 minutes to complete and does require photo uploads. All information and photos must be submitted in full before Dr. Torres can review your case and provide an accurate quote. This form is HIPAA compliant and your information will remain secure.*

Thank you for your interest in our liposuction, fat transfer & BBL procedures. Before submission, please first review our current surgical minimum requirements:

BMI from 18 up to approximately 34
Age 18-60
Healthy
Good skin elasticity
Positive outlook & realistic expectations

If you dont know your BMI, it will auto-calculate below when you enter your height and weight.

Full Name:

First NameLast Name

Contact Number:

Format: (000) 000-0000.

Email Address:

example@example.com

How did you hear about us?

How soon are you looking to book?

ZIP code:

What is your preferred virtual consultation method?

Please enter your Instagram @ name:

Height (feet):

e.g. If you're 5'4" select "5" here

Height (inches):

e.g. If you're 5'4" select "4" here

Weight (in pounds):

e.g. 132 lbs

Your BMI is:

Note: if your BMI is slightly over 32, don't stress! Dr. Torres does sometimes make exceptions.

Date of Birth:

e.g. 12/23/1997

Do you have any medical conditions?:

Please select any medical condition(s) that apply to you. If you have a medical condition that is not listed, please select "other" and write it in:

Please provide more details (e.g. type of heart condition, specific diagnosis, etc.):

Have you ever had a blood clot or pulmonary embolism?:

Has anyone in your family ever had a blood clot or pulmonary embolism?:

Are you currently taking any medications?:

Please list all medications below:

Have you had any previous surgeries, procedures (cosmetic + non-cosmetic), or butt injections?:

Please list each procedure and the approx. date it was performed:

Have you had serious complications from previous surgeries or cosmetic procedures?:

Do you smoke/vape/use any nicotine products?

Have you had any pregnancies?:

Please list the number of pregnancies, births, and date of last birth:

Do you have any allergies?

Please list all allergies below:

What treatment are you most interested in?:

Please select all lipo areas you are interested in treating below:

Are you interested in adding on any other additional areas? :

Are you interested in including a fat transfer to the breasts?

Are you interested in adding on/receiving a quote for Renuvion J-Plasma skin tightening?

What is your estimated budget?

📷 Please upload clear, unedited, and unfiltered photos taken in good lighting. These photos help Dr. Torres assess your candidacy and accurately provide you with a personalized quote.

👉 Body Contouring Procedures (Lipo360, BBL, abdomen, flanks, etc.):

Wear a bikini or low rise underwear/bra
Be sure to include front, side, and back views of your full body
Stand naturally with arms relaxed by your sides
No high rise or full coverage bottoms as it makes it difficult to assess lower abdomen, skin laxity, and fat distribition
Transfer to breast: please ensure full breast area is visable for evaluation

👉 Small Individual Areas (arms/chin only):

Please upload front, back, and side views of the area
Make sure the entire area is visable *no zoom or crop please*
Wear clothing that allows the area to be seen clearly

👉 AlloClae/Sculptra:

Please follow "body contouring procedures" instructions above

Upload Here

What are your goals with this procedure?:

How would you describe your ideal result? (optional):

Inspo/Goal Photos (optional):

Upload 1-2 photos that represent your aesthetic goals. Please choose images that clearly show the shape or look you're hoping to achieve. If you have more reference photos, you're welcome to email them to us after submitting this form or review them with Dr. Torres during your consultation.

Would you be open to letting us share your results/transformation on our social media (with your privacy always respected)?

*Note: We NEVER post intake photos submitted through this form or any private images- only content we created together in office and photos/vids you approve of!*

Please confirm the following:

*Ignore this* height (hidden/old)

e.g. 5 feet

*ignore this* weight (hidden, old)

e.g. 132lbs

*ignore this* height (hidden/old)

e.g. 4 inches

total height calculation (hidden)

Consultation Intake Form

Contact Information

Medical History

Areas of Interest

Submit Your Photos

Personal Goals