Beautologie Consultation Request

WELCOME TO BEAUTOLOGIE!
Thank you for your interest in Beautologie! Gathering this information from you is the first step in the consultation process! By completing this form, we will have all the information we need to help you have an informative virtual or in-office consultation with a member of our team.
We can't wait to meet you!
Please tell us a little about yourself.
First Name*
Last Name*
Date of Birth*
Sex*
Female
Male
E-mail Address*
by entering your email address, you consent to email communication
Cell Phone*
by entering your cell phone number, you consent to text and phone communication
Are you currently a patient of Beautologie (seen us in the last 12 months)?*
Yes
No
How did you hear about Beautologie?*
Please feel free to describe in detail in "Other"
What was your friends or family name?
Please include their first and last name. We won't let them know you contacted us but would love to send them a small gift for their referral of our newest patient.
How can we help you? What procedures are you interested in?
What type of procedure are you interested in?*
Cosmetic Surgery
Medical Aesthetics (Botox, fillers, lasers...)
Both
Which location do you prefer for you Cosmetic Surgery procedure(s)?*
Bakersfield
Fresno
Stockton
Temecula
Other:
Which location do you prefer for your Medical Aesthetics procedure(s)?*
Bakersfield
Fresno
Medical Aesthetics are ONLY performed in Bakersfield and Fresno at this time
Which female procedure are you interested in?
Breast Implants
Breast Lift
Breast Reduction
Tummy Tuck
Buttock Augmentation (BBL)
Liposuction
Thigh Lift
Arm Lift
Other:
Check as many as you like!
Which male procedure are you interested in?
Gynecomastia (male breast) removal
Liposuction
Tummy Tuck
Hair Transplant
Other:
Check as many boxes as you like
Which medical aesthetics procedures are you interested in?
Wrinkle Relaxers (Botox, Dysport, etc)
Fillers (Restylane, Juvaderm, others...)
Non invasive fat removal
Laser hair removal
Laser tattoo removal
Face laser procedures
Face Skin tightening
Cellulite removal (Endermologie)
Non invasive fat removal (CoolSculpt/ Cooltone)
Non Invasive buttock augmentation
Other:
Check as many as you'd like!
When would you like to have the procedure done?
I have a specific date in mind
ASAP (the soonest date you have available)
In the next 3 months
In the next 6 months
In the next 12 months
Other:
What is your preferred date to try to reserve for your procedure?
We cannot guarantee any specific day, but we will work hard to accommodate you!
Height
Weight (lbs.)
Your Body Mass Index is over 35. Our guidelines allow consultations for patients below a 35 BMI. Would you be interested in learning more about our Medical Weight Loss Program?*
Yes
No
Please tell us in your own words what you would like to achieve with this procedure
Thank you! Let's set up your Consultation appointment.
Consultations are $25 and this fee covers the cost of the consultation and is applied to the procedure or treatment when moving forward. Choose from a Virtual Visit via Zoom or book at the office with a member of our team. A mask will be required, at the office and we ask that you come alone to your consult. Thank you for your understanding!
What type of consultation would you like?*
Virtual ZOOM Consult with a member of our team ($25)
In Person Consult with a member of our team ($25)
What is your preferred language to have your consultation?
English
Spanish
Do you have the ZOOM videoconference app installed on your computer or device?
Yes
No
Zoom is the most effective way to have a Virtual Consult, and it is complimentary!
We will send you a link to install ZOOM (free app) could you do this for your consult? Which platform do you use?
iPhone or Ipad
Android phone
Mac desktop
PC desktop
Zoom allows us to share pictures, slides, and more! It's super easy and free! ...download the app at zoom.com
Which day works best for your MEDICAL AESTHETICS Consultation? Please check all that apply.
Monday
Tuesday
Wednesday
Thursday
Friday
We offer complimentary Zoom Consultations with members of our aesthetic team. Zoom consultations with Dr. Milan Shah are $50 and the fee can be applied towards your procedure when moving forward.
What time of day works best for your MEDICAL AESTHETICS consultation?*
9:00 AM - 12:00 PM
12:00 PM - 3:00 PM
3:00 PM - 6:00 PM
Please select all that apply
Which day of the week works best for you for your COSMETIC SURGERY CONSULTATION?*
Monday
Tuesday
Wednesday
Thursday
Friday
Choose all that apply
Which time period works best for you for your COSMETIC SURGERY CONSULTATION?
9am - 11am
11am - 1pm
1pm - 3pm
3pm - 5pm
Choose all that apply
In cosmetic surgery, a picture is worth a 1000 words! Uploading your photos for evaluation makes your consult process smooth and easy because we will know exactly what to offer you. Are you able to take your photos and upload them now?*
Yes
No
Please, upload these photos so we can give you the best information possible.
Click here for photo instructions. You only need to send us the pictures requested on this form. If you want to submit any more pictures, or if you are unable to upload here now, please send them to secure@beautologie.com. Thank you!
Please upload ONE FRONT FULL BODY PICTURE so our doctor can review to make recommendations.
see this WEBSITE for instructions on taking pictures: www.beautologie.com/photos
Please upload ONE SIDE (either side is fine) FULL BODY PICTURE so our doctor can review to make recommendations.
see this WEBSITE for instructions on taking pictures: www.beautologie.com/photos
Please upload ONE BACK FULL BODY PICTURE so our doctor can review to make recommendations.
see this WEBSITE for instructions on taking pictures: www.beautologie.com/photos
Please upload ONE FRONT CHEST PICTURE so our doctor can review to make recommendations.
see this WEBSITE for instructions on taking pictures: www.beautologie.com/photos
Please upload ONE RIGHT SIDE CHEST PICTURE so our doctor can review to make recommendations.
see this WEBSITE for instructions on taking pictures: www.beautologie.com/photos
Please upload ONE LEFT SIDE CHEST PICTURE so our doctor can review to make recommendations.
see this WEBSITE for instructions on taking pictures: www.beautologie.com/photos
Please upload ONE FRONTAL FACE PICTURE so our doctor can review to make recommendations.
see this WEBSITE for instructions on taking pictures: www.beautologie.com/photos
Please upload ONE LEFT SIDE FACE PICTURE so our doctor can review to make recommendations.
see this WEBSITE for instructions on taking pictures: www.beautologie.com/photos
Please upload ONE RIGHT SIDE FACE PICTURE so our doctor can review to make recommendations.
see this WEBSITE for instructions on taking pictures: www.beautologie.com/photos
Please upload ONE PICTURE OF THE AREA so our doctor can review to make recommendations.
see this WEBSITE for instructions on taking pictures: www.beautologie.com/photos
Since you have not been to our facility before, or it has been more than a year, we need to obtain some basic medical information.
Please fill out the medical history below accurately and completely.
Medical History*
None
Lung disease of any type
Anemia
Heart disease of any type
Asthma
Atrial Fibrillation
Cancer
Cerebrovascular Accident/ Stroke
Cronary Artery Disease / Stents
COPD (Emphysema)
Crohn's Disease
Diabetes
Hepatitis C
Hypertension
Liver Disease
Myocardial Infarction (heart attack)
Renal (kidney) Disease
Blood clotting disorder
Pulmonary Embolism
Other:
Check any past/current patient problems
Psychological History*
None
OCD
ADHD
Depression
Schizophrenia
Other:
Please list all surgeries you have had in the past*
None
Other:
Anything else we should know about your health history?
Scheduling a consultation for cosmetic surgery requires a $25 fee. Please enter your credit card info below to complete your consult request. Entering your credit card authorizes Beautologie to charge your card in the amount of $25.00.
4
Scheduling a consultation for medical aesthetics requires a $25 fee. Please enter your credit card info below to complete your consult request. Entering your credit card authorizes Beautologie to charge your card in the amount of $25.00.
3
3