Patient Evaluation Medical Form

This form is requested to evaluate the candidacy for any plastic surgery procedure.

Age

Height

Weight

What procedures are you interested in?

Brazilian Butt Lift Liposuction Tummy Tuck Breast Augmentation Breast Lift Breast Lift With Implants Breast Reduction Eyelid Surgery Face Lift Nose Reshaping-Rhinoplasty Gynecomastia Other

Name

Phone Number

Take a front picture of the body area you'd like to enhance, make sure to not include your face. ( Front View )

Take a side picture of the body area you'd like to enhance, make sure to not include your face. ( Right Side View )

Take a side picture of the body area you'd like to enhance, make sure to not include your face. ( Left Side View )

Take a photo of the area you would like to improve, make sure not to include your face. (View from the back)

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1 (786) 347-9140
info@miamilakescosmetics.com
15450 New Barn Rd, Miami Lakes, FL 33014

We offer a weekly newsletter with the latest updates from our blog. We will also send you some exclusive offers and discounts.

This is a great way to get your hands on some of the best deals and to stay up-to-date with all the latest happenings in the world of plastic surgery.

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Patient Evaluation Medical Form

We offer a weekly newsletter with the latest updates from our blog. We will also send you some exclusive offers and discounts.

This is a great way to get your hands on some of the best deals and to stay up-to-date with all the latest happenings in the world of plastic surgery. Subscribe To Our newsletter

This is a great way to get your hands on some of the best deals and to stay up-to-date with all the latest happenings in the world of plastic surgery.

Subscribe To Our newsletter