do or do not , there is no try check that box Name Email Phone Number Address City State Zip Date of Birth/Age Height Weight What procedure are you interested in? Brazilian Butt Lift via Fat Transfer Brazilian Butt Lift via Butt Implants Brazilian Butt Lift via Butt Implants & Fat Transfer Breast Augmentation with Saline Implants Breast Augmentation with Silicone Implants Breast Augmentation with Lift Breast Lift Breast Reduction Gynecomastia (Male Breast Reduction) Liposuction Tummy Tuck Mini Tummy Tuck Mommy Makeover Vaginal Rejuvenation Vaginoplasty Labiaplasty G-Spot Enhancement Hymenoplasty Brachioplasty (Arm Lift) Otoplasty Thigh Lift Lower Body Lift Back Lift (Braline Lift) Vaser Liposuction Vaser Lipo Etching Blepharoplasty (Eyelid Surgery) Brow Lift (Forehead Lift) Chin Augmentation Cheek Augmentation Lip Augmentation Otoplasty Neck Lift Facelift Injectables / Dermal Fillers Hair Transplant Neograft IV Therapy Do you have any medical problems? Please List them. Have you had any previous surgeries? Please List them. What medications do you take on a daily basis? Do you smoke? Yes No If yes, how much and for how many years. Are you interested in having multiple procedures done at the same time? Yes No How do you plan to pay for the procedure? Cash Check Credit Card Apply for Financing Please Answer These Questions If You Are Planning To Have Any Type Of Breast Surgery.How many children have you had? Did you breast feed? Yes No If yes, for how long on average? Do you plan on having children in the future? Yes No If yes, when? Have you had any problems with your breasts (such as cysts, lumps, abnormal discharge, skin changes, etc)? Yes No If yes, please list: Have any close relatives had breast cancer? Yes No The last mammogram I had was: Never had one Less than one year ago More than one year ago What type of implants are you interested in? Saline Silicone Not Sure What Bra size do you currently wear? What cup size do you want to be after surgery (approximate)? Upload your Pictures Picture 1 Picture 2 Picture 3
*Moises Salama M.D.
