Consultation Questionnaire

This info will be used to help our doctor determine the specifics that may be needed for your case. The only access will be to the medical team.

Overview

Estimated 5 minutes*

Personal Details

Some basic information we need to get to know you

  • What's your name?
  • How old are you?
  • What's your gender?
Medical History

Your health history that is important to consider

  • Do you have any diseases?
  • What is your surgical history?
  • Do you drink or smoke?
  • Pregnant or on hormone pills/birth control?
Upload Photos (optional)

Photo's of your target area for an exact quote

  • Picture #1 (front)
  • Picture #2 (left)
  • Picture #3 (right)