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Cart
Shop
Accessories
Health & Wellness
Pre-Made Packages
Build Recovery Box
Custom Faja
Services
Studio
Mobile Services
Recovery Suites
Telehealth
Training
Consultation
Contact Us
Policies
Surgery Blog
Menu
Shop
Accessories
Health & Wellness
Pre-Made Packages
Build Recovery Box
Custom Faja
Services
Studio
Mobile Services
Recovery Suites
Telehealth
Training
Consultation
Contact Us
Policies
Surgery Blog
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Your Information
–
Step
1
of 7
Please complete this form after booking mobile services or services at our New York Studio.
Name
*
First
Last
Date of Birth
*
Address
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Kingdom of)
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
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India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
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Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
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Nicaragua
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Nigeria
Niue
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Northern Mariana Islands
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Palau
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Panama
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Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
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United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Next
Email
*
Phone Number
*
Gender
*
Female
Male
Select an option
Age
*
Previous
Next
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 you pregnant or think you may be pregnant?
*
Yes
No
Previous
Next
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
Next
Are you interested in receiving services at our New York Studio?
*
Yes
No
Select all that apply:
*
Post Op Care (Lymphatic Massages)
Tape Method
Drain Removal
Seroma Treatment
Advanced Post Op Care
Injections
Body Contouring
Teeth Whitening
IV Vitamin Infusions
Vagi Spa
Counseling
Other
Body Contouring
*
Sauna Wrap
Ultrasound Cavitation
Radio Frequency (Skin Tightening)
Lipo Laser
Wood Therapy
Butt Plumping
Cellulite Blaster
Injections
*
Keloid Shot
Lipo Shot
BBL-PRP
Vagi Spa
*
Waxing
Yoni Steam
Vajacial
Vaginal Rejuvenation
IV Vitamin Infusions
*
B12 (IM)
Skinny Shot (IM)
Glutathione (IM)
Pure Hydration
Immunity (Pre Op)
Snatched
BBL Booster
Glow (Skin)
Glow (Hair)
Swell Less (Post Op)
Vagi
Select all that apply
Previous
Next
Are you interested in our mobile services?
*
Yes
No
Where would you like to receive mobile services?
*
New York (NYC, Queens, Brooklyn, Bronx, Long Island)
Miami (West Miami, South Miami, Coral Gables)
Select all that apply:
*
Post Op Care (Lymphatic Massages)
Seroma Treatment
Tape Method
Private Nursing
IV Vitamin Infusions
Meal Prep (Miami Only)
Other
Will the provider need to walk up one or more flight of stairs?
*
Yes
No
Do you have a pet(s)?
*
Yes
No
Nursing rates
*
Registered Nurse $50/HR
Select an option
How many hours of care will you need?
*
4 HOUR (MIN)
How many days will you require assistance?
*
IV vitamin infusions
*
B12 (IM)
Skinny Shot (IM)
Glutathione (IM)
Pure Hydration
Immunity (Pre Op)
Snatched Drip
BBL Booster
Glow (Skin)
Glow (Hair)
Swell Less (Post Op)
Select all that apply
Meal prep rates (delivery included)
*
5 for $100
10 for $165
Other
How many meals will you require?
*
List food preferences and food allergies
*
Previous
Next
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.
*
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Signature
*
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