Introductory Information Form

Note: all information sent or given to our offices will be held in the strictest of confidence and not told to anyone without your written permission. Filling out this form completely helps us give you a better idea of how we might be of service to you. It is up to the patient how much information you wish to provide. For example providing us with your phone number is optional if you feel that we can communicate properly by regular mail, e-mail, fax, etc.: Don't forget to click the "Send Form" button at the bottom of this form after filling out the information you provide.

Patient's Last Name Patient's First Name
E-mail address
Telephone Number (with area code if within USA):
Best time or way for our staff to contact you:
Country (if other than USA):
Age group:   18-25 years   25-35   35-45   45-55   55+
Height: feet       inches;      or meters
Weight: pounds; or kilogram

Place a checkmark in the areas that you the patient think would benefit from liposuction
(please see drawing/diagram):

FA = Face
NE = Neck
UA = Upper arms
MB = Male breasts
AA = Anterior abdomen = front of tummy
LA = Lateral abdomen = hips = "love handles" in men
BU = Buttocks
OT = Lateral or outer thighs (upper legs) = saddle bags
IT = Inner thighs
KN = Knees
LL = Lower legs = calves labeled diagram of body
AN = Ankles

Finally, it is very helpful to have pictures of you to form the most accurate opinions regarding potential liposuction. Here are some possible ways for us to see your photographs: 1) e-mail of digital photographs, 2) scanning of Polaroid® or other photographs, 3) regular or overnight
mail of digital images on computer disks or of Polaroid® or other photographic images.

Suggestions for good/useful photographs:

1. A digital camera makes the process easy for e-mail.
2. It is nice to use a delay timer on the camera initiate the photo or to have a friend take the photo.
3. Front, back and side pictures of the area to be treated are helpful.
4. You can "block out" your face (if you prefer) from a regular photograph with dark tape, or taped paper.
5. You can use the computer to block out or remove your face from a digital image if you so desire.
6. A large full - length mirror can be used to take a photograph of yourself if necessary.
7. Most patients prefer to wear black bikinis or tight, small underwear for proper yet modest viewing.
8. Feet should be 18 inches apart in lower body photographs
9. The body or areas of desired treatment should occupy over half of the area of the photo but less than the entire picture.
10. Good examples of helpful photographs may be seen in our "before and after section" just turn to the side as well. Too much "free space" may make your image appear too small or distant. Even a photo containing head and toes should not be too distant.

* Recommended Options

Please add any additional information or comments in the box below.

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