Assessment Form

Please answer each question. Should not take more than a few minutes!

Personal Details

Once you have filled out all of the personal detail questions please read our privacy policy and sign your name below if you understand everything and then move on to the questions.

Name *

Date of Birth (DOB) *

Email *

Phone Number *

Height *

Weight *

Personal Details

Address

Street Address

City

State

Country

Postal code

Questions

Please answer all questions in this section as honestly and accurately as possible, if you answer YES to any question please give further details in the next box.

Have you or any of your family had problems with to anaesthesia? *

Yes

No

If answered yes to problems with anaesthesia, please provide further details. If answered No, please put N/A. *

Questions

Are you a smoker? *

Yes

No

How much do you smoke? *

1-5 per day

6-10 per day

11-15 per day

16-20 per day

Only on social occasions

Not Applicable

Questions

Do you use or take illegal substances? *

Yes

No

If answered yes, please provide further details. If answered No, please put N/A. *

Questions

Do you use or take herbal supplements? *

Yes

No

If answered yes, please provide further details. If answered No, please put N/A. *

Questions

Are you currently breastfeeding? *

Yes

No

If answered yes, please provide further details. If answered No, please put N/A. *

Questions

Do you use a gym/sauna/steam room? *

Yes

No

If answered yes, please provide further details. If answered No, please put N/A. *

Questions

Have you been pregnant or given birth? *

Yes

No

Is there a chance you could be pregnant? *

Yes

No

If answered yes, please provide further details. If answered No, please put N/A. *

Please enter the dates of your pregancy / childbirths - including type of delivery.

Questions

Are you currently taking birth control? *

Yes

No

If answered yes, please provide further details. If answered No, please put N/A. *

Questions

Have you ever lost excess weight? *

Yes

No

If answered yes, please provide further details. If answered No, please put N/A. *

Questions

Have you ever had an allergic reaction? *

Yes

No

If answered yes, please provide further details. If answered No, please put N/A. *

Questions

Do you have any allergies? *

Yes

No

If answered yes, please provide further details. If answered No, please put N/A. *

Questions

Have you contracted Covid 19? *

Yes

No

If answered yes, please provide further details. If answered No, please put N/A. *

Questions

Did you receive your covid vaccination or plan to? *

Yes

No

If answered yes, please provide further details. If answered No, please put N/A. *

Other information

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

Low Blood Pressure

Heart Disease

High 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

Previous DVT or Lung Embolus

Bleeding or clotting disorder

Sickle Cell

Thyroid Disease

Cancer

Skin Diseases

Ulcers or Gastritis

Obstructive Sleep Apnea

Persistent Cough

Motion Sickness

Depression

Hepatitis HIV

HIV

Blood Transfusion

NONE

If answered yes to any of these, please provide further details. If answered yes, please provide further details. If answered No, please put N/A. *

Other information

Do you have any upcoming surgergies / procedures / treatments? *

Yes

No

If answered yes, please provide further details. If answered No, please put N/A. *

Other information

What is the treatment / procedure you are interested in and what would you like to achieve? *

Do you have Breast Implants? *

Yes

No

If answered yes, please provide further details. If answered No, please put N/A. *

Other information

Have you ever had surgery before? *

Yes

No

If answered yes, please provide further details. If answered No, please put N/A. *

Other information

Do you have Buttock or any other Implants? *

Yes

No

If answered yes, please provide further details. If answered No, please put N/A. *

Other information

Do you plan to have a surgical BBL (liposuction and fat transfer) in the future? *

Yes

No

Where did you hear about us? *

How to take your images

Upload a photo

Please upload full size images, no angles, from each side. You can also upload 360 video instead. *

I have read and understood the terms & conditions and the privacy policy.

Signature *

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