Consult 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.
Your 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
Your mailing address to prepare your medical chart.

How did you hear about Beautologie?*
Please feel free to describe in detail in "Other"
What is your friend's or family member's name if someone referred you to us?
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?  Check all that apply, as many as you'd like.
What type of procedure are you interested in? Please check all that apply.*
Cosmetic Surgery
Medical Aesthetic Treatments (Botox, fillers, lasers and more...)
Wellness (Weight Loss, Hormone Replacement Therapy...)
Which medical aesthetics procedures are you interested in? Check as many as you'd like.*
Wrinkle Relaxers (Botox, Dysport, etc)
Fillers (Restylane, Juvaderm, others...)
Laser hair removal
Laser tattoo removal
Face laser procedures
Face Skin tightening
Cellulite removal (Endermologie)
Non invasive fat removal (CoolSculpt/ Cooltone)
Morpheus8
Non Invasive buttock augmentation
Ink/Inkless Scar or Stretch Mark Camouflage
Medical Weight Loss
Hormone Replacement Therapy
IV Therapy
Supplements
Other:
*Medical Aesthetics services are currently available in Bakersfield. Fresno and Newport Beach exclusively.
Which female procedure are you interested in? Check as many you'd like.
Breast Implants
Breast Lift
Breast Reduction
Tummy Tuck
Buttock Augmentation (BBL)
Liposuction
Thigh Lift
Arm Lift
Face Lift / Neck Lift
Brow Lift
Blepharoplasty (upper and/or lower eye surgery)
Rhinoplasty (Nose surgery)
Chin Augmentation/Chin Implant
Other:
 
Which male procedure are you interested in? Check as many as you'd like.
Gynecomastia (male breast) reduction
Liposuction
Tummy Tuck
Face Lift/Neck Lift
Blepharoplasty (upper and/or lower eyelid surgery)
Brow Lift
Rhinoplasty (nose surgery)
Chin Augmentation/Chin Implant
Neograft Hair Transplant
Other:
 
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!
Are you currently a patient of Beautologie (seen us in the last 12 months)?*
Yes
No
How much do you weigh in pounds?
Height
Weight (lbs.)
Your Body Mass Index is over 40. Our guidelines allow consultations for patients below a 40 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 or procedures you have selected.
Thank you! Let's set up your Consultation appointment.
Choose from a Virtual appointment via Zoom or book at the office with a member of our team. Selecting your prefered day and time will allow us to schedule this for you based on your selections. We will send you the appoitnment confirmation details by email and text message.
What type of consultation would you like?*
Virtual Zoom Consultation with a member of our team
In-office consultation with a member of our team
I am not sure, please give me a call.
We are currently offering complimentary consultations and have in-person and virtual Zoom options available at no charge. Please select the option(s) that work for you.
What is your preferred language to have your consultation?
English
Spanish
Which location do you prefer for you Cosmetic Surgery procedure(s)?
Bakersfield
Fresno
Stockton
Which location do you prefer for your Medical Aesthetics and/or Wellness treatment(s)?*
Bakersfield
Fresno
Newport Beach
*Medical Aesthetic services are exclusively available in Bakersfield, Fresno and Newport Beach.
Which day works best for your MEDICAL AESTHETICS/WELLNESS Consultation? Please check all that apply. We will schedule your appointment based on your selections.
Monday
Tuesday
Wednesday
Thursday
Friday
What time of day works best for your MEDICAL AESTHETICS/WELLNESS Consultation? Please check all that apply. We will schedule your appointment based on your selections.
9:00 AM - 12:00 PM
12:00 PM - 3:00 PM
3:00 PM - 6:00 PM
 
Which day of the week works best for your COSMETIC SURGERY CONSULTATION? Please check all that apply. We will schedule your appointment based on your selections.*
Monday
Tuesday
Wednesday
Thursday
Friday
 
Which time window works best for your COSMETIC SURGERY CONSULTATION? Consultations take about an hour.  Please check all that apply. We will schedule your appointment based on your selections.
10:00 AM
12:00 PM
1:30 PM
3:00 PM
 
In our industry, a picture is worth a 1000 words! Uploading your photos for evaluation makes your virtual 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
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*
Anything else we should know about your health history?
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.
Please upload ONE SIDE (either side is fine) FULL BODY PICTURE so our doctor can review to make recommendations.
Please upload ONE BACK FULL BODY PICTURE so our doctor can review to make recommendations.
Please upload ONE FRONT CHEST PICTURE so our doctor can review to make recommendations.
Please upload ONE RIGHT SIDE CHEST PICTURE so our doctor can review to make recommendations.
Please upload ONE LEFT SIDE CHEST PICTURE so our doctor can review to make recommendations.
Please upload ONE FRONTAL FACE PICTURE so our doctor can review to make recommendations.
Please upload ONE LEFT SIDE FACE PICTURE so our doctor can review to make recommendations.
Please upload ONE RIGHT SIDE FACE PICTURE so our doctor can review to make recommendations.
Please upload ONE PICTURE OF THE AREA so our doctor can review to make recommendations.