Consult Request
WELCOME TO BEAUTOLOGIE!
Thank you for your interest in Beautologie Cosmetic Sugery!
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*
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Sex assigned at birth*
Female
Male
E-mail Address*
by entering your email address, you consent to email communication
Cell Phone*
By providing my contact information to Beautologie, I acknowledge and give my explicit consent to be contacted via SMS and receive emails for various purposes, which may include marketing and promotional content. Message and data rates may apply. Message frequency may vary. Reply STOP to opt-out. Reply HELP for more help.
How did you hear about Beautologie?*
Select one...
A friend or family member
Internet search (Google, Bing, or Yahoo...)
A review website like Yelp, Realself, or Google reviews
Social media (instagram or facebook)
An ad on radio, tv, or in a magazine
Our newsletter
A billboard
I don't remember
Other:
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.
What procedures are you interested in? Check all that apply.
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
Otoplasty (ear surgery - not earlobe repair)
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)
Otoplasty (ear surgery - not earlobe repair)
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?
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Feb
Mar
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We cannot guarantee any specific day, but we will work hard to accommodate you!
How were you planning on paying for the procedure?
Cash or Credit Card
I have a Care Credit or Alphaeon Card
I NEED TO apply for financing
I have a loan or alternate method of payment arranged
Other:
Choose your antipated payment method (as many as you like).
Height
4'10"
4'11"
5'0"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
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5'11"
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6'11"
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7'5"
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 prepare for your Consultation appointment.
Choose from a Virtual appointment via Zoom or book at the office with a member of our team.
What type of consultation would you like?*
Virtual Zoom Consultation with a member of our team (all locations)
In-office consultation with a member of our team (Fresno and Stockton)
We are currently offering complimentary zoom or in-person consultations.
What is your preferred language to have your consultation?*
English
Spanish
Which location do you prefer for your Cosmetic Surgery procedure(s)?*
Bakersfield
Fresno
Stockton
Which day of the week works best for your consultation appointment? Check as many as you'd like.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday (available only for surgery consultations at this time)
What time of day works best for your consultation appointment? Check as many as you'd like.
9:00 AM - 12:00 PM
12:00 PM - 3:00 PM
3:00 PM - 6:00 PM
Are you currently a patient of Beautologie (seen us in the last 12 months)?*
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 12 months and be sure to include the date of the surgery.
Anything else we should know about your health history?
