optimalhealthtoday.com Accent Laser: Cellulite Reduction and Body Sculpting Laser, Ardmore, Gladwyne, Devon, Bryn Mawr, Bala, Cynwyd, Rittenhouse, Mainline, Philadelphia, PA, 877-642-2644

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Serving: Ardmore, Mainline, and Center City Philadelphia, Bryn Mawr, Haverford, Villanova, Gladwyne, Narberth, Wynnewood, Bala Cynwyd, Paoli, Devon, Delaware Cherry Hill, Haddonfield, Penn Valley, Radnor, Wayne, Lower Merion

Accent Laser Cellulite Reduction Body Contouring
Patient Questionnaire

We would like to know more about your unique personal goals for cellulite reduction and body contouring. Cellulite affects 70% of women of reproductive age and beyond. Diet and exercise may be helpful, however they rarely rid women of this problem. The first step to addressing this problem is to identify your goals. Please tell us more about you. This medical information is intended as an informational service for internal purposes only.

Name:
E Mail:
Confirm Email:
Date:
Address:
Daytime Phone Number:
Your Age:
Weight:
Height:
Reasons you are considering liposuction (check all that apply)	Feel better about myself Look better in swimsuit Lose inches Please spouse / lover Fit better in clothing Lose weight Improve physical image Change hereditary problem
What are your expectations?
Do you have loose skin or "cellulite"?
Describe your body frame:	Slight Medium Heavy
How does your doctor rate your health?
List any medical / health problems:
List any medications that you take:
Please check if you have a history of the following:	High blood pressure Bleeding tendency / clotting problem Heart condition (including murmur, mitral valve prolapse) Hernias Transfusions: Date:
Please list previous surgeries and please note if you have had liposuction in the past:
Have you had complications from any surgery or anesthesia?
If yes, please describe:
Please list any allergies:
Thank you. We look forward to speaking with you and meeting you in the future.