e-consults

General Information
Please note this e-consult may take up to 10 minutes! Thank you!
Name/Nombre*

First NameMiddle NameLast Name
Date of Birth / Fecha de nacimiento*

MonthDayYear
Date
Gender / Genero*
Email / Correo*
example@example.com
Address / Addresion*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number / Numero de telefono*

Area CodePhone Number
Will you need finance options?*
What is your ideal procedure date / Cual es su fecha de procedimiento ideal?*

Within a monthWithin 3 months3 to 6 months6 to 12 months12+ months
Tell us what procedure(s) you're interested in / Cual procedimiento o servicios uste estas interesado!*
Tell us what you would like to accomplish through these procedures! Diaganos lo que le gustaria lograr a traves de estos procedimientos!
Health Information
Height / Estatura*
Weight / El peso *
What is your BMI? / Cual es tu BMI?
Are you in good health? / Estas en buena salud?*

YesNo
If you pressed no above, please explain why / Si no presiono nada de arriba, por favor explique por que *
Are you pregnant? / Estas embarazada?*

YesNo
Have you been hospitalized or had a serious illness within the past 5 years? / Algun vez ha sido hospitalizado con una enfermedad grave en los ultimos 5 anos?*

YesNo
Have you had prior cosmetic/plastic procedures? / Ha tenido procedimientos cosmeticos/plasticos previos?*

YesNo
Do you have, or have had, any of the following diseases/problems? / Tiene o ha tenido alguna de las siguientes enfermedades?*

Active Cancer or LeukemiaBleeding DisorderChronic Viral InfectionDiabetesHeart AttackHepatitis or other liver diseasesHIV/AIDSLupus, or LCERheumatic FeverSeizures or Neurological DisordersSickle Cell DiseaseStrokeI do not have, or have not had, any of the diseases mentioned above
Do you have allergies to any medications? / Tiene alguna alergia a los medicamentos?*

YesNo
Are you allergic or have you reacted adversely in any way to the following? / es alergico o ha reaccionado negativamente de alguna manera a lo siguiente*

Local anesthesiaPenicillin or other antibioticsSulfa drugsBarbiturates, sedatives, or sleeping pillsAspirinIodineNone of the above
Do you have any disease, condition, or problem not listed that you think Millennial Plastic Surgery should be aware of? / Tiene alguna enfermedad, condicio, o problema que usted piensa que el Millennial Plastic Surgery debe ser consciente de?*

YesNo
If so, please explain / Si es asi, por favor explique *
Finance

If you are interested in our finance options, please contact our office. We are pleased to also offer in house financing. si usted esta interesado en nuestras opciones de finanzas, por favor pongase en contacto con nuestra oficina. nos complace ofrecer tambien financiacion en la casa.
Photos
- Please make sure your photos are taken in a well lit area.
- For privacy reasons, you do not have to show your face.
- You may wear undergarments/bikinis in your photo.
Front View Shot*

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Left Side View*

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Right Side View*

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Rear View Shot*

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By clicking submit, I certify that all information is true and correct to the best of my knowledge and agree to Millennial Plastic Surgery's privacy policy and to be contacted regarding our promotions.
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General Information

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Photos