Facial Procedure Photos

Name*

Email*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Procedures of Interest (select all that apply):*

Areas of Concern (select all that apply)*

Stomach
Back
Thighs
Buttocks and/or hips
Face
Breasts
Arms

Date of Birth*

BMI Calculation

Weight (in lbs.)*

Height (in inches)*

BMI

Photos

Please take clear, well-lit photos of the area(s) you are inquiring about. Be sure the entire area is visible and not covered by clothing. You may wear undergarments, a bikini, or choose to take the photos nude—whatever you are most comfortable with—as long as the treatment area is fully shown. If you are submitting photos for a breast procedure, please ensure your breasts are fully visible in the images without a bra or clothing. For procedures involving multiple areas (e.g., back, stomach, thighs), please include photos from multiple angles (front, back, and side views if possible) to help us best assess your needs.

Right Side View Photo*

Max. file size: 2 GB.

Front Side View Photo*

Max. file size: 2 GB.

Left Side View Photo*

Max. file size: 2 GB.

Back View Photo*

Max. file size: 2 GB.

Medical History

Do you smoke? (select all that apply)*

No
Yes - cigarettes
Yes - vape
Yes - THC
Yes - other

Surgical History and Approximate date*

Past and Ongoing Medical Problems*

Heavy menstrual bleeding/diagnosed blood disorder*

Yes
No

Do you have Anemia?*

Yes
No

Approximate date you would like your surgical procedure?*

Please list any medications are you current taking (including vitamines and supplements)*

Occupation*

Number of children and their ages*

Instagram handle

Any additional information you would like to share:

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Blepharoplasty

Face Lift

Rhinoplasty

Schedule A Consultation

BMI Calculation

Photos

Medical History