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Shop
Services
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Surgery Blog

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Contact Us
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Surgery Blog

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

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 you 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)
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

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 *

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 *

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 *

Name

FAQ

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