miamilifeplasticsurgery.com
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urlscan Pro
2606:4700:3035::ac43:9ba7
Public Scan
Submitted URL: https://psurgery-xvd.verifyhosts.com/
Effective URL: https://miamilifeplasticsurgery.com/evaluation-form//
Submission: On March 16 via api from US — Scanned from US
Effective URL: https://miamilifeplasticsurgery.com/evaluation-form//
Submission: On March 16 via api from US — Scanned from US
Form analysis 2 forms found in the DOM
Name: New Form — POST
<form class="elementor-form" method="post" name="New Form">
<input type="hidden" name="post_id" value="18109">
<input type="hidden" name="form_id" value="9f45e75">
<input type="hidden" name="referer_title" value="Evaluation Form - Miami Life Plastic Surgery">
<input type="hidden" name="queried_id" value="18109">
<div class="elementor-form-fields-wrapper elementor-labels-above">
<div class="elementor-field-type-hidden elementor-field-group elementor-column elementor-field-group-invitation elementor-col-100">
<input size="1" type="hidden" name="form_fields[invitation]" id="form-field-invitation" class="elementor-field elementor-size-sm elementor-field-textual">
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-procedureinterested elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-procedureinterested" class="elementor-field-label"> What Procedure are you <span class="blue">interested in? </span></label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[procedureinterested]" id="form-field-procedureinterested" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Brazilian Butt Lift">Brazilian Butt Lift</option>
<option value="Breast Procedure">Breast Procedure</option>
<option value="Liposuction">Liposuction</option>
<option value="Mommy Make Over">Mommy Make Over</option>
<option value="Tummy Tuck">Tummy Tuck</option>
<option value="V-Zone">V-Zone</option>
<option value="I don't know yet">I don't know yet</option>
</select>
</div>
</div>
<div class="elementor-field-type-date elementor-field-group elementor-column elementor-field-group-desiredsurgerydate elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-desiredsurgerydate" class="elementor-field-label"> Desired <span class="blue">Surgery Date </span></label>
<input type="date" name="form_fields[desiredsurgerydate]" id="form-field-desiredsurgerydate" class="elementor-field elementor-size-sm elementor-field-textual elementor-date-field" required="required" aria-required="true"
pattern="[0-9]{4}-[0-9]{2}-[0-9]{2}">
</div>
<div class="elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_7f765ec elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_7f765ec" class="elementor-field-label"> Date of <span class="blue">Birth </span></label>
<input type="date" name="form_fields[field_7f765ec]" id="form-field-field_7f765ec" class="elementor-field elementor-size-sm elementor-field-textual elementor-date-field" required="required" aria-required="true"
pattern="[0-9]{4}-[0-9]{2}-[0-9]{2}">
</div>
<div class="elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_609761d elementor-col-25 elementor-field-required elementor-mark-required">
<label for="form-field-field_609761d" class="elementor-field-label"> Height <span class="blue">(Feet) </span></label>
<input type="number" name="form_fields[field_609761d]" id="form-field-field_609761d" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="5" required="required" aria-required="true" min="" max="">
</div>
<div class="elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_21aa947 elementor-col-25 elementor-field-required elementor-mark-required">
<label for="form-field-field_21aa947" class="elementor-field-label"> Height <span class="blue">(Inches) </span></label>
<input type="number" name="form_fields[field_21aa947]" id="form-field-field_21aa947" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="6" required="required" aria-required="true" min="" max="">
</div>
<div class="elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_fd2b633 elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_fd2b633" class="elementor-field-label"> Weight in <span class="blue">pounds </span></label>
<input type="number" name="form_fields[field_fd2b633]" id="form-field-field_fd2b633" class="elementor-field elementor-size-sm elementor-field-textual" required="required" aria-required="true" min="" max="">
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_8daca11 elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_8daca11" class="elementor-field-label"> How often do you <span class="blue">smoke? </span></label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_8daca11]" id="form-field-field_8daca11" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Regularly">Regularly</option>
<option value="Casually">Casually</option>
<option value="Not at all">Not at all</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_75638fe elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_75638fe" class="elementor-field-label"> How often do you drink <span class="blue">alcohol? </span></label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_75638fe]" id="form-field-field_75638fe" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Regularly">Regularly</option>
<option value="Casually">Casually</option>
<option value="Not at all">Not at all</option>
</select>
</div>
</div>
<div class="elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_5d37334 elementor-col-100 elementor-field-required elementor-mark-required">
<label for="form-field-field_5d37334" class="elementor-field-label"> If you have had any <span class="blue">surgical procedures</span> in the past, please describe them here and inlude the dates: </label>
<textarea class="elementor-field-textual elementor-field elementor-size-sm" name="form_fields[field_5d37334]" id="form-field-field_5d37334" rows="1" required="required" aria-required="true"></textarea>
</div>
<div class="elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_25e3368 elementor-col-100 elementor-field-required elementor-mark-required">
<label for="form-field-field_25e3368" class="elementor-field-label"> Do you do any <span class="blue">drugs</span> if so mention them below: </label>
<textarea class="elementor-field-textual elementor-field elementor-size-sm" name="form_fields[field_25e3368]" id="form-field-field_25e3368" rows="1" required="required" aria-required="true"></textarea>
</div>
<div class="elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_a6f4451 elementor-col-100 elementor-field-required elementor-mark-required">
<label for="form-field-field_a6f4451" class="elementor-field-label"> If you are on any <span class="blue">medications</span> currently, mention them below: </label>
<textarea class="elementor-field-textual elementor-field elementor-size-sm" name="form_fields[field_a6f4451]" id="form-field-field_a6f4451" rows="1" required="required" aria-required="true"></textarea>
</div>
<div class="elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_97f4df2 elementor-col-100 elementor-field-required elementor-mark-required">
<label for="form-field-field_97f4df2" class="elementor-field-label"> If you have any <span class="blue">genetic disorder</span> mention it below: </label>
<textarea class="elementor-field-textual elementor-field elementor-size-sm" name="form_fields[field_97f4df2]" id="form-field-field_97f4df2" rows="1" required="required" aria-required="true"></textarea>
</div>
<div class="elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_97d168d elementor-col-100 elementor-field-required elementor-mark-required">
<label for="form-field-field_97d168d" class="elementor-field-label"> If you have any <span class="blue">drug or other allergies</span> mention them below: </label>
<textarea class="elementor-field-textual elementor-field elementor-size-sm" name="form_fields[field_97d168d]" id="form-field-field_97d168d" rows="1" required="required" aria-required="true"></textarea>
</div>
<div class="elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_c9b5fb8 elementor-col-100 elementor-field-required elementor-mark-required">
<label for="form-field-field_c9b5fb8" class="elementor-field-label"> If you have had <span class="blue">any Natural births, Abortions or C-section in the past</span> mention them here and include the dates : </label>
<textarea class="elementor-field-textual elementor-field elementor-size-sm" name="form_fields[field_c9b5fb8]" id="form-field-field_c9b5fb8" rows="1" required="required" aria-required="true"></textarea>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_bc4727f elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_bc4727f" class="elementor-field-label"> Any <span class="blue">abortion</span> or <span class="blue">miscarriage</span> last 3 months </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_bc4727f]" id="form-field-field_bc4727f" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_532afa2 elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_532afa2" class="elementor-field-label"> Have you given <span class="blue">birth</span> in the last 6 months? </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_532afa2]" id="form-field-field_532afa2" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_42d5af3 elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_42d5af3" class="elementor-field-label"> Do you have any <span class="blue">buttocks Injections</span> ? </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_42d5af3]" id="form-field-field_42d5af3" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_f9c4c38 elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_f9c4c38" class="elementor-field-label"> Do you have <span class="blue">sickle cell</span> trait? </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_f9c4c38]" id="form-field-field_f9c4c38" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_d9bdf72 elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_d9bdf72" class="elementor-field-label"> Do you have <span class="blue">sickle cell</span> disease? </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_d9bdf72]" id="form-field-field_d9bdf72" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_bb80ee2 elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_bb80ee2" class="elementor-field-label"> Any <span class="blue">history</span> of Deep vein thrombosis? </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_bb80ee2]" id="form-field-field_bb80ee2" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_bb84f36 elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_bb84f36" class="elementor-field-label"> Any <span class="blue">history</span> of Pulmonary Embolism? </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_bb84f36]" id="form-field-field_bb84f36" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_151976f elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_151976f" class="elementor-field-label"> Do you have <span class="blue">diabetes, thyroid problems (hypothyroidism or hyperthyroidism)?</span> </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_151976f]" id="form-field-field_151976f" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_59e3d3e elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_59e3d3e" class="elementor-field-label"> Do you have <span class="blue">Multiple Sclerosis (MS)?</span> </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_59e3d3e]" id="form-field-field_59e3d3e" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_4d50940 elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_4d50940" class="elementor-field-label"> Do you have <span class="blue">Epilepsy?</span> </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_4d50940]" id="form-field-field_4d50940" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_5a14929 elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_5a14929" class="elementor-field-label"> Do you have <span class="blue">Autoimmune disease?</span> </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_5a14929]" id="form-field-field_5a14929" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_db1b1d9 elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_db1b1d9" class="elementor-field-label"> Any history of <span class="blue">Strokes?</span> </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_db1b1d9]" id="form-field-field_db1b1d9" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_da4d8eb elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_da4d8eb" class="elementor-field-label"> Do you have <span class="blue">Glaucoma?</span> </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_da4d8eb]" id="form-field-field_da4d8eb" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_427e3ab elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_427e3ab" class="elementor-field-label"> Do you take any weight-loss products <span class="blue">(Phentermine, Herbalife, any Amphetamine like Aderoll, Ritolin, Vyvanse, Concerta or Other) ?</span> </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_427e3ab]" id="form-field-field_427e3ab" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_5270ae6 elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_5270ae6" class="elementor-field-label"> Are you vaccinated for <span class="blue">COVID-19?</span> </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_5270ae6]" id="form-field-field_5270ae6" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_fd79f5d elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_fd79f5d" class="elementor-field-label"> Have you had <span class="blue">COVID-19?</span> before? </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_fd79f5d]" id="form-field-field_fd79f5d" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_d5b4427 elementor-col-100 elementor-field-required elementor-mark-required">
<label for="form-field-field_d5b4427" class="elementor-field-label"> If you have any conditions on your <span class="blue">Heart, Lungs, Kidneys, Head, etc</span> mention them here: </label>
<textarea class="elementor-field-textual elementor-field elementor-size-sm" name="form_fields[field_d5b4427]" id="form-field-field_d5b4427" rows="1" required="required" aria-required="true"></textarea>
</div>
<div class="elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_9085b9b elementor-col-100 elementor-field-required elementor-mark-required">
<label for="form-field-field_9085b9b" class="elementor-field-label"> If you have any other <span class="blue">medical conditions</span> mention them here: </label>
<textarea class="elementor-field-textual elementor-field elementor-size-sm" name="form_fields[field_9085b9b]" id="form-field-field_9085b9b" rows="1" required="required" aria-required="true"></textarea>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_e236423 elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_e236423" class="elementor-field-label"> Would you be interested in <span class="blue">financing</span>? </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_e236423]" id="form-field-field_e236423" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_a91311b elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_a91311b" class="elementor-field-label"> Would you be interested in <span class="blue">medspa</span> services? </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_a91311b]" id="form-field-field_a91311b" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="No">No</option>
<option value="Yes">Yes</option>
</select>
</div>
</div>
<div class="elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_276bfef elementor-col-100">
<h6 style="text-align: center">Great! Now the only thing that you have to do is to <span class="blue">tap on the button down below</span> so you can submit the previous form and go to a Secure Link so you can <span class="blue">upload your
pictures. </span></h6>
<h6 style="text-align: center">We are going to need pictures of your <span class="blue">front, back, and sides. </span></h6>
</div>
<div class="elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons">
<button type="submit" class="elementor-button elementor-size-sm">
<span>
<span class=" elementor-button-icon">
</span>
<span class="elementor-button-text">Submit Form and <span class="blue">Upload Pictures</span>
</span>
</span></button>
</div>
</div>
</form>Name: New Form — POST
<form class="elementor-form" method="post" name="New Form">
<input type="hidden" name="post_id" value="18109">
<input type="hidden" name="form_id" value="7afc276">
<input type="hidden" name="referer_title" value="Evaluation Form - Miami Life Plastic Surgery">
<input type="hidden" name="queried_id" value="18109">
<div class="elementor-form-fields-wrapper elementor-labels-above">
<div class="elementor-field-type-hidden elementor-field-group elementor-column elementor-field-group-invitation elementor-col-100">
<input size="1" type="hidden" name="form_fields[invitation]" id="form-field-invitation" class="elementor-field elementor-size-sm elementor-field-textual">
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-procedureinterested elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-procedureinterested" class="elementor-field-label"> En qué procedimiento está<span class="blue"> interesad@? </span></label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[procedureinterested]" id="form-field-procedureinterested" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Brazilian Butt Lift">Brazilian Butt Lift</option>
<option value="Aumento de senos">Aumento de senos</option>
<option value="Liposucción">Liposucción</option>
<option value="Mommy Make Over">Mommy Make Over</option>
<option value="Abdominoplastia">Abdominoplastia</option>
<option value="V-Zone">V-Zone</option>
<option value="Otro">Otro</option>
</select>
</div>
</div>
<div class="elementor-field-type-date elementor-field-group elementor-column elementor-field-group-desiredsurgerydate elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-desiredsurgerydate" class="elementor-field-label">
<span class="blue">fecha de cirugía</span> deseada </label>
<input type="date" name="form_fields[desiredsurgerydate]" id="form-field-desiredsurgerydate" class="elementor-field elementor-size-sm elementor-field-textual elementor-date-field" required="required" aria-required="true"
pattern="[0-9]{4}-[0-9]{2}-[0-9]{2}">
</div>
<div class="elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_7f765ec elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_7f765ec" class="elementor-field-label"> Fecha de <span class="blue">Nacimiento </span></label>
<input type="date" name="form_fields[field_7f765ec]" id="form-field-field_7f765ec" class="elementor-field elementor-size-sm elementor-field-textual elementor-date-field" required="required" aria-required="true"
pattern="[0-9]{4}-[0-9]{2}-[0-9]{2}">
</div>
<div class="elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_609761d elementor-col-25 elementor-field-required elementor-mark-required">
<label for="form-field-field_609761d" class="elementor-field-label"> Altura <span class="blue">(Metros) </span></label>
<input type="number" name="form_fields[field_609761d]" id="form-field-field_609761d" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="1" required="required" aria-required="true" min="" max="">
</div>
<div class="elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_6c0a9b5 elementor-col-25 elementor-field-required elementor-mark-required">
<label for="form-field-field_6c0a9b5" class="elementor-field-label"> Altura <span class="blue">(Centim) </span></label>
<input type="number" name="form_fields[field_6c0a9b5]" id="form-field-field_6c0a9b5" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="70" required="required" aria-required="true" min="" max="">
</div>
<div class="elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_fd2b633 elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_fd2b633" class="elementor-field-label"> Peso en<span class="blue"> libras </span></label>
<input type="number" name="form_fields[field_fd2b633]" id="form-field-field_fd2b633" class="elementor-field elementor-size-sm elementor-field-textual" required="required" aria-required="true" min="" max="">
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_8daca11 elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_8daca11" class="elementor-field-label">
<span class="blue">Fuma</span> Regularmente? </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_8daca11]" id="form-field-field_8daca11" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Regularmente">Regularmente</option>
<option value="Casualmente">Casualmente</option>
<option value="Nunca">Nunca</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_75638fe elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_75638fe" class="elementor-field-label"> Consume <span class="blue">alcohol</span> regularmente? </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_75638fe]" id="form-field-field_75638fe" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Regularmente">Regularmente</option>
<option value="Casualmente">Casualmente</option>
<option value="Nunca">Nunca</option>
</select>
</div>
</div>
<div class="elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_5d37334 elementor-col-100 elementor-field-required elementor-mark-required">
<label for="form-field-field_5d37334" class="elementor-field-label"> Si ha tenido algún <span class="blue">procedimiento quirúrgico </span> en el pasado, descríbalo acá e incluya las fechas: </label>
<textarea class="elementor-field-textual elementor-field elementor-size-sm" name="form_fields[field_5d37334]" id="form-field-field_5d37334" rows="1" required="required" aria-required="true"></textarea>
</div>
<div class="elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_a6f4451 elementor-col-100 elementor-field-required elementor-mark-required">
<label for="form-field-field_a6f4451" class="elementor-field-label"> Si consume alguna <span class="blue"> droga </span> menciónela acá: </label>
<textarea class="elementor-field-textual elementor-field elementor-size-sm" name="form_fields[field_a6f4451]" id="form-field-field_a6f4451" rows="1" required="required" aria-required="true"></textarea>
</div>
<div class="elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_c829966 elementor-col-100 elementor-field-required elementor-mark-required">
<label for="form-field-field_c829966" class="elementor-field-label"> Si está consumiendo alguna<span class="blue"> medicación</span> menciónela acá: </label>
<textarea class="elementor-field-textual elementor-field elementor-size-sm" name="form_fields[field_c829966]" id="form-field-field_c829966" rows="1" required="required" aria-required="true"></textarea>
</div>
<div class="elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_acdcec1 elementor-col-100 elementor-field-required elementor-mark-required">
<label for="form-field-field_acdcec1" class="elementor-field-label"> Si tiene algún <span class="blue"> desorden genético</span> menciónelo acá: </label>
<textarea class="elementor-field-textual elementor-field elementor-size-sm" name="form_fields[field_acdcec1]" id="form-field-field_acdcec1" rows="1" required="required" aria-required="true"></textarea>
</div>
<div class="elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_97d168d elementor-col-100 elementor-field-required elementor-mark-required">
<label for="form-field-field_97d168d" class="elementor-field-label"> si tiene <span class="blue">alergias</span> a algún medicamento u otra alergia menciónela debajo: </label>
<textarea class="elementor-field-textual elementor-field elementor-size-sm" name="form_fields[field_97d168d]" id="form-field-field_97d168d" rows="1" required="required" aria-required="true"></textarea>
</div>
<div class="elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_6a7d8c1 elementor-col-100 elementor-field-required elementor-mark-required">
<label for="form-field-field_6a7d8c1" class="elementor-field-label"> si ha tenido <span class="blue">partos, Abortos o cesáreas</span> menciónelos acá e incluya las fechas: </label>
<textarea class="elementor-field-textual elementor-field elementor-size-sm" name="form_fields[field_6a7d8c1]" id="form-field-field_6a7d8c1" rows="1" required="required" aria-required="true"></textarea>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_532afa2 elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_532afa2" class="elementor-field-label"> Ha entrado en <span class="blue">parto</span> en los últimos 6 meses? </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_532afa2]" id="form-field-field_532afa2" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Sí">Sí</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_bc4727f elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_bc4727f" class="elementor-field-label"> Ha tenido <span class="blue">aborto</span> o <span class="blue">malparto</span> en los últimos tres meses? </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_bc4727f]" id="form-field-field_bc4727f" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Sí">Sí</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_f9c4c38 elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_f9c4c38" class="elementor-field-label"> Tienes sustancias inyectadas en los <span class="blue">glúteos?</span> </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_f9c4c38]" id="form-field-field_f9c4c38" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Sí">Sí</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_c75d760 elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_c75d760" class="elementor-field-label"> Padece algún tipo de <span class="blue">anemia</span>? </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_c75d760]" id="form-field-field_c75d760" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Sí">Sí</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_c0241cd elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_c0241cd" class="elementor-field-label"> Tienes algun desorden sanguíneo <span class="blue">( Rasgo de células falciformes, talasemia)?</span> </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_c0241cd]" id="form-field-field_c0241cd" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Sí">Sí</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_bb80ee2 elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_bb80ee2" class="elementor-field-label"> Tiene algún historial de <span class="blue">trombosis venosa profunda? </span></label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_bb80ee2]" id="form-field-field_bb80ee2" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Sí">Sí</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_bb84f36 elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_bb84f36" class="elementor-field-label"> Tiene algún historial de<span class="blue"> embolia pulmonar? </span></label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_bb84f36]" id="form-field-field_bb84f36" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Sí">Sí</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_5e607ab elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_5e607ab" class="elementor-field-label"> diabetes, problemas con la tiroides <span class="blue"> (hipertiroidismo o hipotiroidismo)? </span></label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_5e607ab]" id="form-field-field_5e607ab" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Sí">Sí</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_ec4d92e elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_ec4d92e" class="elementor-field-label">
<span class="blue">Esclerosis Múltiple ? </span></label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_ec4d92e]" id="form-field-field_ec4d92e" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Sí">Sí</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_db53c28 elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_db53c28" class="elementor-field-label">
<span class="blue"> Epilepsy? </span></label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_db53c28]" id="form-field-field_db53c28" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Sí">Sí</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_a8d8640 elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_a8d8640" class="elementor-field-label">
<span class="blue">Enfermedades autoinmunes? </span></label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_a8d8640]" id="form-field-field_a8d8640" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Sí">Sí</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_fa02a71 elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_fa02a71" class="elementor-field-label"> apoplejía o <span class="blue">ataques cerebrales? </span></label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_fa02a71]" id="form-field-field_fa02a71" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Sí">Sí</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_8dc7d1b elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_8dc7d1b" class="elementor-field-label">
<span class="blue">Glaucoma? </span></label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_8dc7d1b]" id="form-field-field_8dc7d1b" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Sí">Sí</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_80116fe elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_80116fe" class="elementor-field-label"> Tomas algún producto para la pérdida de peso?<span class="blue">(Phentermine, herbalife, alguna anfetamina como aderoll, Ritolin, Vyvanse, Concerta u otra?) </span></label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_80116fe]" id="form-field-field_80116fe" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Sí">Sí</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_59e6aaa elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_59e6aaa" class="elementor-field-label"> Estás vacunad@ contra el <span class="blue">COVID-19? </span></label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_59e6aaa]" id="form-field-field_59e6aaa" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Sí">Sí</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_b21e66d elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_b21e66d" class="elementor-field-label"> Has padecido de <span class="blue">COVID-19? </span></label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_b21e66d]" id="form-field-field_b21e66d" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Sí">Sí</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_1ba103e elementor-col-100 elementor-field-required elementor-mark-required">
<label for="form-field-field_1ba103e" class="elementor-field-label"> Si tiene alguna <span class="blue">condición</span> en su corazón, pulmones, rinones u otro descríbala acá: </label>
<textarea class="elementor-field-textual elementor-field elementor-size-sm" name="form_fields[field_1ba103e]" id="form-field-field_1ba103e" rows="1" required="required" aria-required="true"></textarea>
</div>
<div class="elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_ffa303f elementor-col-100 elementor-field-required elementor-mark-required">
<label for="form-field-field_ffa303f" class="elementor-field-label"> Si tiene alguna otra <span class="blue">condición médica</span> descríbala acá: </label>
<textarea class="elementor-field-textual elementor-field elementor-size-sm" name="form_fields[field_ffa303f]" id="form-field-field_ffa303f" rows="1" required="required" aria-required="true"></textarea>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_e236423 elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_e236423" class="elementor-field-label"> Estaría interesad@ en <span class="blue">financiamiento?</span> </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
</div>
<select name="form_fields[field_e236423]" id="form-field-field_e236423" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Sí">Sí</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_3004901 elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-field_3004901" class="elementor-field-label"> Estaría interesad@ en nuestros servicios de <span class="blue">MedSpa? </span></label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<i aria-hidden="true" class="eicon-caret-down"></i>
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<select name="form_fields[field_3004901]" id="form-field-field_3004901" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Sí">Sí</option>
<option value="No">No</option>
</select>
</div>
</div>
<div class="elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_276bfef elementor-col-100">
<h6 style="text-align: center">Perfecto! Ahora lo único que debes hacer es <span class="blue">presionar el botón de abajo</span> para que puedas submitir el formulario y <span class="blue">subir tus fotografías </span>a través de nuestro link
seguro. </h6>
<h6 style="text-align: center">Vamos a necesitar fotos de tu <span class="blue">frente, espalda y costados. </span></h6>
</div>
<div class="elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons">
<button type="submit" class="elementor-button elementor-size-sm">
<span>
<span class=" elementor-button-icon">
</span>
<span class="elementor-button-text">Submitir Formalario y <span class="blue">Subir fotografías</span>
</span>
</span></button>
</div>
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</form>Text Content
Skip to content * Home Page * Procedures * Brazilian Butt Lift * Breast Augmentation * Liposuction * Mommy Makeover * Tummy Tuck * V-Zone * Wellness Services * Surgeons * Dr. James McAdoo * Dr. Constantine Kitsos * Dr. Michael Miller * Dr. Daniel Kaufman * Dr. Camille Chavez * Dr. Nassif Souied * Dr Robert Kagan * Dr. Daniel Zeichner * Dr. Onyeka Nwokocha * Linktree * Contact Page Menu * Home Page * Procedures * Brazilian Butt Lift * Breast Augmentation * Liposuction * Mommy Makeover * Tummy Tuck * V-Zone * Wellness Services * Surgeons * Dr. James McAdoo * Dr. Constantine Kitsos * Dr. Michael Miller * Dr. Daniel Kaufman * Dr. Camille Chavez * Dr. Nassif Souied * Dr Robert Kagan * Dr. Daniel Zeichner * Dr. Onyeka Nwokocha * Linktree * Contact Page In order to serve you more conveniently, please fill out this evaluation form for your online assessment. Our knowledgeable patient consultant will review it, help determine the best surgical option and contact you within 24 business hours. (Please check Spam folder) What Procedure are you interested in? Brazilian Butt Lift Breast Procedure Liposuction Mommy Make Over Tummy Tuck V-Zone I don't know yet Desired Surgery Date Date of Birth Height (Feet) Height (Inches) Weight in pounds How often do you smoke? Regularly Casually Not at all How often do you drink alcohol? Regularly Casually Not at all If you have had any surgical procedures in the past, please describe them here and inlude the dates: Do you do any drugs if so mention them below: 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 : Any abortion or miscarriage last 3 months Yes No Have you given birth in the last 6 months? Yes No Do you have any buttocks Injections ? No Yes Do you have sickle cell trait? Yes No Do you have sickle cell disease? Yes No Any history of Deep vein thrombosis? Yes No Any history of Pulmonary Embolism? Yes No Do you have diabetes, thyroid problems (hypothyroidism or hyperthyroidism)? Yes No Do you have Multiple Sclerosis (MS)? Yes No Do you have Epilepsy? Yes No Do you have Autoimmune disease? Yes No Any history of Strokes? Yes No Do you have Glaucoma? Yes No Do you take any weight-loss products (Phentermine, Herbalife, any Amphetamine like Aderoll, Ritolin, Vyvanse, Concerta or Other) ? Yes No Are you vaccinated for COVID-19? Yes No Have you had COVID-19? before? Yes No If you have any conditions on your Heart, Lungs, Kidneys, Head, etc mention them here: If you have any other medical conditions mention them here: Would you be interested in financing? No Yes Would you be interested in medspa services? No Yes GREAT! NOW THE ONLY THING THAT YOU HAVE TO DO IS TO TAP ON THE BUTTON DOWN BELOW SO YOU CAN SUBMIT THE PREVIOUS FORM AND GO TO A SECURE LINK SO YOU CAN UPLOAD YOUR PICTURES. WE ARE GOING TO NEED PICTURES OF YOUR FRONT, BACK, AND SIDES. Submit Form and Upload Pictures Para brindarle un servicio más conveniente, complete este formulario para su evaluación en línea. Su consultora lo revisará, ayudará a determinar la mejor opción quirúrgica y se comunicará con usted dentro de 24 horas hábiles. En qué procedimiento está interesad@? Brazilian Butt Lift Aumento de senos Liposucción Mommy Make Over Abdominoplastia V-Zone Otro fecha de cirugía deseada Fecha de Nacimiento Altura (Metros) Altura (Centim) Peso en libras Fuma Regularmente? Regularmente Casualmente Nunca Consume alcohol regularmente? Regularmente Casualmente Nunca Si ha tenido algún procedimiento quirúrgico en el pasado, descríbalo acá e incluya las fechas: Si consume alguna droga menciónela acá: Si está consumiendo alguna medicación menciónela acá: Si tiene algún desorden genético menciónelo acá: si tiene alergias a algún medicamento u otra alergia menciónela debajo: si ha tenido partos, Abortos o cesáreas menciónelos acá e incluya las fechas: Ha entrado en parto en los últimos 6 meses? Sí No Ha tenido aborto o malparto en los últimos tres meses? Sí No Tienes sustancias inyectadas en los glúteos? Sí No Padece algún tipo de anemia? Sí No Tienes algun desorden sanguíneo ( Rasgo de células falciformes, talasemia)? Sí No Tiene algún historial de trombosis venosa profunda? Sí No Tiene algún historial de embolia pulmonar? Sí No diabetes, problemas con la tiroides (hipertiroidismo o hipotiroidismo)? Sí No Esclerosis Múltiple ? Sí No Epilepsy? Sí No Enfermedades autoinmunes? Sí No apoplejía o ataques cerebrales? Sí No Glaucoma? Sí No Tomas algún producto para la pérdida de peso?(Phentermine, herbalife, alguna anfetamina como aderoll, Ritolin, Vyvanse, Concerta u otra?) Sí No Estás vacunad@ contra el COVID-19? Sí No Has padecido de COVID-19? Sí No Si tiene alguna condición en su corazón, pulmones, rinones u otro descríbala acá: Si tiene alguna otra condición médica descríbala acá: Estaría interesad@ en financiamiento? Sí No Estaría interesad@ en nuestros servicios de MedSpa? Sí No PERFECTO! AHORA LO ÚNICO QUE DEBES HACER ES PRESIONAR EL BOTÓN DE ABAJO PARA QUE PUEDAS SUBMITIR EL FORMULARIO Y SUBIR TUS FOTOGRAFÍAS A TRAVÉS DE NUESTRO LINK SEGURO. VAMOS A NECESITAR FOTOS DE TU FRENTE, ESPALDA Y COSTADOS. Submitir Formalario y Subir fotografías MAIN OFFICE 8686 Coral Way,Miami, FL 33155 SUNSET LOCATION 7130 SW 87th Ct, Miami, FL 33173 This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. * Main Office Phone: (305) 507 8848 * Email: info@miamilifeplasticsurgery.com Privacy Policy