Evaluation Form - Huka Cosmetic Center

Intake Form

Fill out this short Intake Form so your surgeon can evaluate your desired procedure.

Date of Birth

Height in Feet

Height in Inches

Weight

Age

Gender

Home Address

Drivers Licence #

Pharmacy

Language Preference

Medical History

Current Medications

Medication Allegies

Past Surgical Procedures

Recreational drug use

If you use any recreational drugs please mention them

Smoker

If you are a smoker, how frequently do you smoke?

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone Number

How did you hear from us?

Who is yout Insurance Carrier if any?

Whats your procedure of interest?

Acerca de nosotros

En Huka Cosmetic Center ofrecemos una variedad de procedimientos cosméticos relacionados con inyectables, cara y cuello, liposucción y otros. ¡Utilice uno de nuestros muchos canales de comunicación para reservar su procedimiento hoy!

Doctores

Links

Contáctenos

Spanish