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Shop
Services
Training
Consultation
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Surgery Blog

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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
Suture Removal
Drain Removal
Seroma Treatment
Advanced Post Op Care
Injections
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)

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

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

Yes
No

Select all that apply: *

Post Op Care (Lymphatic Massages)
Presso Therapy
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 *

Email

FAQ

FAQ

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