Evaluation Form 2 - Smart Plastic Surgery

Evaluation Form

Please fill out this form to start your transformation journey! At the end of the form, the SUBMIT button will take you to a website to upload your pictures. Our coordination team will be ready for you when you are finished.

What procedure are you interested in?

Desired Surgery Date

Date of Birth

Height (Feet, Inches)

Weight in Pounds

How often do you smoke?

How often do you drink alcohol?

If you have had any surgical procedures in the past, please describe them here and inlude the dates:

If you are on any medications currently, mention them below:

If you have any genetic disorder mention it below:

If you have any drug or other allergies mention them below:

If you have had any Natural births, Abortions or C-section in the past mention them here and include the dates :

Do you have any buttocks Injections ?

Do you have sickle cell trait?

Do you have sickle cell disease?

Any history of Deep vein thrombosis?

Any history of Pulmonary Embolism?

Do you have diabetes, thyroid problems (hypothyroidism or hyperthyroidism)?

Do you have Multiple Sclerosis (MS)?

Do you have Epilepsy?

Do you have Glaucoma?

Do you take any weight-loss products (Phentermine, Herbalife, any Amphetamine like Aderoll, Ritolin, Vyvanse, Concerta or Other) ?

Are you vaccinated for COVID-19?

Have you had COVID-19? before?

If you have any other medical conditions mention them here:

Would you be interested in financing?

Perfect! The next step would be to tap on the button down below to submit the form.

Evaluation Form

Procedures

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