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Shop
Services
Training
Consultation
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Surgery Blog

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Services
Training
Consultation
Contact Us
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Surgery Blog

Your Information – Step 1 of 7

Please complete this form ONLY after booking and paying deposit

Name *

First

Last

Date of Birth *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Phone Number *

Gender *

Select an option

Age *

Do you have any allergies to medication? *

Yes
No

List all allergies *

Are you taking any medication(s) or vitamin(s)? *

Yes
No

List all medication(s) or vitamin(s) *

Do you have any pre-existing health issues/diseases? If yes, please explain *

Are your pregnant or think you may be pregnant? *

Yes
No

Did you have surgery or are planning to have surgery? *

Yes
No

Name of Surgeon *

Country or State *

Date of procedure(s) *

Type of procedure(s) *

Liposuction
BBL (Fat Transfer)
Tummy Tuck
Breast Augmentation
Breast Lift
Other

Select all that apply

Are you interested in receiving services at our New York Studio? *

Yes
No

Select all that apply: *

Post Op Care (Lymphatic Massages)
Presso Therapy
Cryo Therapy
Tape Method
Suture Removal
Drain Removal
Seroma Treatment
Advanced Post Op Care
Injections
Scar Therapy
Body Contouring
Teeth Whitening
IV Vitamin Drips
Vagi Spa
Other

Body Contouring *

Sauna Wrap (Infrared)
Maui Lipo (Cavitation, Lipo Laser, RF)
Wet & Wavy (Wood Therapy, Cavitation, Lipo Laser, RF)
Beach Bum (Vacuum Therapy)
Bali Body (Venus Legacy)
Cellulite Blaster (Venus Legacy)

Scar Therapy *

Chemical Peel
Microneedling-PRP

Injections *

Keloid Shot
BBL-PRP

IV Vitamin Infusions *

B12 (IM)
Skinny Shot (IM)
Glutathione (IM)
Pure
Immunity (Pre Op)
Snatched
BBL Booster
Glow (Skin)
Glow (Hair)
Swell Less (Post Op)
Vagi

Select all that apply

Vagi Spa *

Waxing
Yoni Steam
Butt Facial
Vajacial
Intimate Bleaching
Vaginal Rejuvenation

Are you interested in receiving mobile services in Miami, FL? *

Yes
No

Select all that apply: *

Post Op Care (Lymphatic Massages)
Presso Therapy
Tape Method
Body Contouring
Teeth Whitening
IV Vitamin Infusions
Vagi Spa

Body Contouring *

Maui Lipo (Cavitation, Lipo Laser, RF)
Wet & Wavy (Wood Therapy, Cavitation, Lipo Laser, RF)
Beach Bum (Vacuum Therapy)

IV Vitamin Infusions *

B12 (IM)
Skinny Shot (IM)
Glutathione (IM)
Pure
Immunity (Pre Op)
Snatched
BBL Booster
Glow (Skin)
Glow (Hair)
Swell Less (Post Op)

Select all that apply

Vagi Spa *

Waxing
Yoni Steam
Butt Facial
Vajacial

When would you like service(s) to begin? *

Select a date

Recovery Address *

Is this a Recovery House or Hotel? *

Yes
No

Name of RH or Hotel *

Please check with RH if outside providers are allowed PRIOR to booking.

To help us serve you better, please list any additional information.

ALL SALES ARE FINAL: There are no refunds or exchanges on any products or services. *

Type full name

Signature *

Phone

FAQ

FAQ

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