Evaluation Form

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What treatment
might I need?

Take a 5 minutes questionnaire to find out
of what treatments may be suitable for you

  • 1
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  • 3
  • 4

Select your age group

Select gender

  • 1
  • 2
  • 3
  • 4

Please select up to 5 areas of concern

  • Face, Nose, Ears
  • BreastsChest
  • Back
  • Arms
  • Abdominal
  • LabiaGroin
  • Butt
  • Thigh
  • Lower Leg
  • 1
  • 2
  • 3
  • 4

Choose all that apply:

  • Smoking
  • Diabetes
  • High blood pressure
  • History heart disorders
  • History of blood clots
  • Severe obesity
  • Lung disorders
  • HIV infection, or AIDS
  • Hepatitis C
  • Cancer
  • Body dysmorphic syndrome
  • Immune disorders
  • None of the above
  • 1
  • 2
  • 3
  • 4

Personal Details

Thank you

We have received your evaluation and
will return a call to you within 3 to 5 business days.

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