Patient Information

Patient Information
Name

First NameLast Name
Date Of Birth

MonthDayYear
Email
example@example.com
Phone Number

Area CodePhone Number
Instagram:
Photo of identification (Government I.D or Passport)

Browse Files

Cancelof
Emergency Contact

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
Height:
Weight:
Sex:
Number of pregnancies:
Number of children:

Rows	Apply
Are you taking any medications?
Breast cancer in family?
Diet pills/fat burners?
Are you nursing?
Medical allergies?
Have you had any problems with anesthesia?
Do You Smoke?
Do You drink?
Do you use any recreational drugs?
Any type of addiction?
Are you under a doctor's care?
Are you on birth control?
High/Low Blood pressure
Asthma
Kidney Disease
Thyroid disorder
Sickle cell trait/disease
Cardiac pacemaker
Biopolymers (silicone injections/illegal butt shots)
Anemia
Leukemia
AIDS/HIV
Adrenal gland tumor
Heart Disease
Heart Attack
Trombosis
Seizures
Diabetes
STD
Rheumatoid arthritis
Heart murmur
Hepatitis B or C
Recent weight loss

Consulting Agreement

Please review the Lluxe Consultants INC Consulting Agreement below in its entirety before signing.
By signing below, you acknowledge that you have carefully reviewed, fully understand, and voluntarily agree to all terms and conditions outlined in the LLuxe Consultants Inc. Consulting Agreement. Your signature constitutes your acceptance of this agreement.
Client Type Name
Signature
Date

MonthDayYear
Date

Consent & Acknowledgment
By signing below, I certify that the information provided in this form is accurate and complete to the best of my knowledge. I understand that withholding or providing inaccurate information may affect my treatment and surgical outcome. I consent to the collection and use of my personal and medical information for the purpose of evaluating my candidacy for the requested procedure(s).
⚠️ Important Notice

Please note that this is not a live video consultation. This is a virtual consultation in which the surgeon will carefully review the medical history, photographs, and videos you have submitted. Based on the information provided, the surgeon will evaluate your case and prepare a personalized surgical recommendation and quote.
Signature
Date

MonthDayYear
Date

My Products

Consult Service$250.00

Consultation Service Fee The $250 fee is a consultation service fee for the surgeon's virtual evaluation of your case. However, if you choose to recover at LLuxe Recovery, the full $250 will be credited toward your recovery stay balance and applied as your recovery deposit. If you choose not to stay at LLuxe Recovery, the $250 will remain a non-refundable, non-transferable consultation service fee.

Total $0.00

Debit or Credit Card
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Expiration Month	Expiration Year

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Patient Information

Medical History

Procedure Details

Consulting Agreement

Consent & Acknowledgment

My Products

Patient Information

Medical History

Procedure Details

Consulting Agreement

Consent & Acknowledgment

My Products*

My Products