Questionnaire | Réforme Plastic Surgery

next steps

My goals are…*

Let us know your concerns here…We’re listening!

Procedure*

Please select your main procedure of interest

I’d like to schedule my treatment by:

When are you looking to have this done?

Name*

First Name

Last Name

Email*

example@example.com

Phone Number*

Date of Birth*

Mo / Day / Year

height and weight:*

lbs

Feet

Inches

are you trying to lose weight before your procedure?*

do you have any children?*

when was the last time you smoked or vaped?*

have you had any surgeries before?*

Please list out your previous surgeries

do you have a history of blood clots/ dvt?*

do you have any medical issues?*

please tell us about your medical history…*

If you take steroids, have anemia, or a history of blood clots, please let us know.

do you take any medications?*

If Yes, please list your medications and supplements...

You don’t need to include dosing. Just the drug names, please.

do you have any allergies?*

Please list out your known allergies

are you currently working?*

what do you do for work?*

This helps us guide you through your recovery.

how did you hear about dr. raj?*

Think about the first place you saw us!

photos are required to schedule your consult online and for in-person consultations:*

For facial procedures; straight on, both side profiles, in good lighting.

For body procedures; clothed full body photos.

Driver’s license