Lipedema / Liposuction Treatment Form

Age?*

Height (ft)

Weight (lbs)

Do you have pain in your legs?*

Have you ever had any surgery before?*

Have you ever given birth?*

Do you have an allergy?*

Do you have any chronic disease?*

Do you smoke, drink alcohol, or use drugs regularly?*

Do you regularly use medication or do you have a disease?*

Have you ever had a blood transfusion before ?*

When are you planning to have the surgery?*

Have you been diagnosed Lipedema by a doctor?*

Please upload your pictures from 3 sides, like the example above.*

Email*

Phone number

First name*

Last name*

I confirm that all the information provided by me is accurate and complete. Additionally, I authorize the use of the provided health-related information for my health plan. *

I acknowledge that upon arrival, necessary tests will be conducted to assess my eligibility for the surgery. If the results are favorable, the surgery will be scheduled accordingly.*