First Name:

Last Name:

Phone Number:

E-mail Address:

Age:

Height: < 5'0"5'0"5'1"5'2"5'3"5'4"5'5"5'6"5'7"5'8"5'9"5'10"5'11"6'0"6'1"6'2"6'3"6'4"6'5"6'5" >

Weight(lbs):

Date of Birth:

Procedures Interested:
Select a ProcedureBellafillBody LiftBOTOX®Breast AugmentationBreast LiftBreast ReductionBreast RevisionBrowliftCellfina Cellulite TreatmentEyelid SurgeryFaceliftJuvederm®Juvederm® VolumaLaser ServicesLiposuctionMommy MakeoverNeocutisRestylane®Restylane® SilkRhinoplastyTeoxaneTummy TuckOther

For all body procedures please upload a photo of the body exposed from the neck to the knees. We will need a total of 3 pictures (front, side and back). For all facial procedures please upload a total of 3 photos (front and both sides). Maximum File upload Size is 500 MB.

Medications / Supplements you are taking:

Allergies:

Asthma, bronchitis, lung problems?:

Heart disease, angina, arrhythmias, previous heart attack?:

Do you smoke, vape, chew, or ingest nicotine or marijuana in any form?:
 Yes  No

High blood pressure?:
 Yes  No

Diabetes?:
 Yes  No

Kidney disease?:
 Yes  No

Hepatitis or liver disease?:
 Yes  No

Peptic ulcers?:
 Yes  No

Ulcerative colitis or intestinal problems?:
 Yes  No

Lupus, scleroderma, or autoimmunie disorders?:
 Yes  No

Bleeding disorders?:
 Yes  No

HIV or other communicable disease?:
 Yes  No

Cancer treatment, past or present?:
 Yes  No

HIPAA ACKNOWLEDGEMENT

Please be aware that this is a secure email network under HIPAA guidelines. Do not submit any personal or private information unless you are authorized and have voluntarily consented to do so. We are not liable for any HIPAA violations. Understand that if you email us, you are agreeing to the use of this secure method and understand that all replies will be sent by standard (unsecured) email, which you are hereby authorizing. By checking this box you hereby agree to hold Brucker Plastic Surgery, including its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties. 

 By checking this box, I acknowledge my understanding of the HIPAA Policy and agree with its contents.