Spectrum Aesthetics

Tips: Sample how to send Photographs/ Pictures for Evaluation

Submit your photos for evaluation

Your photos will help us to evaluate your case. Please upload your front, side pictures.

Name*
First Last
Email*
Enter Email Confirm Email
Phone
Date Of Birth:*
Sex:*
Height:*
Weight:*
BMI :*
( Click Here to Calculate BMI )
Medical History
Do You Have Any Drug Allergies? If So Please List:*
Do You Take Any Medications, Supplements, Vitamins, Or Birth Control (Including IUD & Patches)? If So Please List:*
Do You Currently Have Any Medical Conditions Or Have You Had Any In The Past?(Ex: Anemia, Asthma, Hyperthyroid, Hypertension, Diabetes, Cancer, Hepatitis, HIV, Etc. ) If so please list:*
Any Family History Of Cancer? If so What Type & What Family Member?:*
Do you have any children?*
- Yes
- No
If you have children, are you breastfeeding? If so, when was the last time you breast fed?*
Have You Ever Been Hospitalized? If so for What & When ?:*
Do you have any history of DVT or Pulmonary embolism? :*
Please List All Medical, Surgical, & Cosmetic Procedures You Have Ever Had*
Please List All Pregnancies, Miscarriages, And Abortions With Date ( Please Note Procedures Must Be 1 Year Post Full Term Pregnancy & 8 Weeks Post Abortions:*
Do You Consume Alcohol? If So How Often?*
Do You Use Any Type of Recreational Drugs? If So Please List Which, How Often & When was the last date of use?*
Do You Smoke, Chew, or are Exposed to Second Hand Smoke of any Form Of Nicotine?*
Do You have Sickle Cell Disease or Sickle Cell Trait? (If so please state which one):*
Procedure Details
Procedure Of Interest*
Date Of Interest:*
Upload photos*
Drop files here or

Accepted file types: jpg, jpeg, gif, png.
Please upload your front, side pictures.
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