Yuliska Sanchez | Plastic Surgery Coordinator | Get Quotation

Name *

First

Last

Email *

Phone *

Age *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Height

Weight

Doctor of choice

Previous surgery

Please describe all medical and cosmetic surgeries in detail with the date. Inform us if you had any complications.

Previous surgery date

Date

Time

Surgery of interest

Date you would like to have your surgery

Do you currently have any health conditions or have you had any in the past?

E.g. anemia, asthma, hyperthyroidism, hypertension, diabetes, hepatitis, HIV, cancer, etc.

Do you have any allergies to medications? If so, please indicate:

Do you have injections of silicon (biopolymers) in the buttocks? *

Do you take medications, vitamins or birth control (including IUDs and patches)? If so, please indicate:

Do you smoke? or the consumption of any recreational drug?

Do you have any psychological or psychiatric disorder? Or do you suffer from anxiety, If so, please indicate and tell us the current treatment.

List all pregnancies, miscarriages, and abortions dated, children:

‼️‼️‼️send 4 photos of front, back, side and side while sitting *

Click or drag files to this area to upload. You can upload up to 4 files.

Photos must be without clothes for evaluation and make sure they have a lot of light, please sink the abdomen.

Quotation Form