LipoSite - Home Page Complimentary Consultation Form
 

Patient:  Please bring this form to your doctor for your complimentary consultation. This form may only be used for a plastic surgeon with the complimentary consultation logo.

Complimentary Consultation

Doctor: Thank you for supporting LipoSite!

Please waive my consultation fee when I bring this form to my consultation at your office.
Information for my plastic surgeon:
My name is: _________________________________

My age: ____________

My height: _____ and weight _______

 I have pictures to show you of my goals: __ yes ___ no

I have had cosmetic surgery before ___ yes ___ no
 
Questions for my plastic surgeon:

--What procedures are available to me? 
--What procedures do you recommend? 
--May I see pictures of your other patients’ results? 
--Do you have any patients I can contact to discuss their results?
--How long before I can work, exercise, etc? 
--Is your operating facility certified?
 

--What risks or complications should I be aware of?
--What is the total cost of the procedure?
--What financing arrangements are available to me?
--What are your policies for revision if I am not satisfied with my result?  What costs are involved, if any?
 

Questions?  Can we make this form better?

Please email [email protected] or fax 888-899-3114

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