Pre-consultation Assessment Form
A personalized assessment with a proposed plan and quotation range will be sent to your email, at NO initial cost.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Weight in kilograms:
*
Height (in feet):
*
What procedure are you interested in?
*
What are your goals or expectations for this procedure?
*
When is your expected timeline to get this procedure done?
*
Budget range (Optional):
Have you had any previous surgeries?
*
Yes
No
If yes, please list previous surgeries (type and year):
Do you have any allergies?
*
Yes
No
If yes, please specify:
Are you currently taking any medications?
*
Yes
No
If yes, please list your current medications:
Do you smoke/vape, or did you in the past and when did you quit if applicable.
*
Yes
No
If yes, please elaborate:
Please share any additional information or questions for your consultation:
*
To help us give you the best assessment and plan, kindly share clear photos showing your areas of concern. Please include views from the left side, right side, and back. Make sure the images are clear and well lit so we can see the details properly. High quality photos allow us to understand your goals fully and create the right treatment plan for you.
*
Browse Files
Drag and drop files here
Choose a file
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of
You may also upload reference photos of the look you wish to achieve. (Optional)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
I agree to receive important updates and messages from Dr. Johanna Baga regarding my account or the services I have requested. These may include appointment reminders, procedure details and other helpful notifications to keep me informed.
*
Please Select
Yes
No
Please note: Only complete and qualified submissions will be reviewed.
Final treatment plans and exact pricing will still depend on a formal in-person or video consultation.
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