Go Back to Home Page Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of Birth *Email *Phone *Address line 1 *Address line 2 *City *State / Province - Postal / Zip code *FirstLastWeight (in kilograms) *Height (in centimeters) *Have you or any of your family had problems with to anaesthesia? *YESNOPEIf answered yes to problems with anaesthesia please provide further details:Are you a smoker? *YESNOPEHow much do you smoke?1-5 per day6-10 per day11-15 per day16-20 per dayOver 20 per dayOnly social occasionsDo you use or take illegal substances? *YESNOPEIf answered yes, please provide further detailsDo you use or take herbal supplements? *YESNOPEIf answered yes, please provide further detailsDo you use a gym / sauna / steam room *YESNOPEIf answered yes, please provide further details How often, how longHave you been pregnant or given birth? *YESNOPEIf answered yes, please provide further details. Please enter the dates of your pregancy / childbirths - including type of delivery...Are you currently breastfeeding? *YESNOPEIs there a chance you could be pregnant? *YESNOPEIf answered yes, please provide further details...Are you currently taking birth control? *YESNOPEIf answered yes, please provide further details...Have you ever lost excess weight? *YESNOPEIf answered yes, please provide further details...Do you have any allergies? *YESNOPEIf answered yes, please provide further details...Have you ever had an allergic reaction? *YESNOPEIf answered yes, please provide further details...Have you contracted Covid 19? *YESNOPEIf answered yes, please provide further details...Did you receive your covid vaccination or plan to? *YESNOPEIf answered yes, please provide further details...Do you suffer from or have you ever suffered from the following... Chest Pains / Tightness or Angina, Previous Rheumatic Fever, Previous Heart Attack, Palpitations, Heart Murmur, Heart Disease, High Blood Pressure, Low Blood Pressure, Artificial Heart Valve or Pacemaker, Hiatus Hernia / Heartburn / Indigestion, Anemia, Diabetes – Oral Medication, Diabetes – Insulin-Dependent, Kidney Disease, Rheumatoid Arthritis, Shortness of breath, Asthma, Emphysema or Bronchitis, Tuberculosis, Stroke or seizures, Jaundice or Hepatitis, Thyroid Disease, Previous DVT or Lung Embolus, Bleeding or clotting disorder, Sickle Cell, Cancer, Skin Desease, Ulcers, Gastritis, Obstructive Sleep Apnoea, Persistent Cough, Motion Sickness, Depression, Hepatitis, HIV, Blood TransfusionDepressionArtificial Heart Valve or PacemakerPrevious DVT or Lung EmbolusSickle CellStroke or seizuresPrevious Rheumatic FeverHigh Blood PressureJaundice or HepatitisTuberculosisUlcersPrevious Heart AttackPalpitationsAsthmaKidney DiseaseSkin DeseaseHiatus Hernia / Heartburn / IndigestionMotion SicknessCancerObstructive Sleep ApnoeaShortness of breathAnemiaThyroid DiseaseHIVEmphysema or BronchitisDiabetes–Insulin-DependentHeart DiseaseBleeding or clotting disorderHepatitisDiabetes–Oral MedicationRheumatoid ArthritisLow Blood PressureHeart MurmurBlood TransfusionPersistent CoughGastritisChest Pains / Tightness or AnginaIf answered yes to any of these, please provide further details...Are you taking or have been prescribed any medication? *YESNOPEIf answered yes to any of these, please provide further details...Is your interest in Surgical or Non-surgical procedures? *Surgical proceduresNon-surgical proceduresBOTHWhat is the treatment / procedure you are interested in and what would you like to achieve? *Which location are you planning to have your procedures? *Do you have any upcoming surgergies / procedures / treatments? *YESNOPEIf answered Yes please give further details:Have you ever had surgery before? *YESNOPEIf answered Yes please give further details:Date and type of each procedure. Any complications or problems since? Any further medical care and when.Do you plan to have a surgical BBL (liposuction and fat transfer) in the future? *YESNOPEIf answered Yes please give further details:For those that plan to have a surgical BBL in the future, a non surgical BBL is not recommended.Do you have Breast Implants? *YESNOPEIf answered YES Please give details such as brand, size and type of implant.Do you have Buttock or any other Implants? *YESNOPEIf answered YES Please give details such as brand, size and type of implant.Pictures or documents about your conditions. * Click or drag files to this area to upload. You can upload up to 5 files. if you have any notes please write here.Submit