Liposculpture Consultation Form
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1. First, please tell us a bit about yourself.
First Name:
*
Last Name:
*
Date of Birth (MM/DD/YYYY):
*
Date Format: MM slash DD slash YYYY
2. Have you ever had cosmetic surgery before?
Have you ever had cosmetic surgery before?
*
Yes
No
2a. Please specify:
Please specify:
*
3. Do you have any pre-existing medical conditions?
Do you have any pre-existing medical conditions?
*
Yes
No
3a. Please provide more information:
Please provide more information:
*
4. Do you smoke?
Do you smoke?
*
Yes
No
5. When would you like to get the procedure done?
When would you like to get the procedure done?
*
Within the next 3 months
Within the next 6 months
Within a years time
Undecided, only inquiring at this time
6. On what part(s) of the body are you looking to have liposculpture performed?
On what part(s) of the body are you looking to have liposculpture performed? (select all that apply)
*
Neck
Arms
Abdomen
Buttocks
Breasts
Thighs
Hips
Knees
Calves
Other
7. Are you currently living a healthy lifestyle?
Are you currently living a healthy lifestyle?
*
Yes, I exercise regularly and eat a healthy diet
I exercise regularly but do not eat well
I eat well but I am mostly sedentary
I rarely exercise and do not pay attention to my food choices
8. What is the best time of day to book your consultation?
What is the best time of day to book your consultation?
Morning
Afternoon
9. How can we reach you?
Email:
*
Phone Number:
*
What is your preferred method of contact?
*
Email
Call
Text
