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Patient Information

Name

First Name

Last Name

Date of Birth

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Gender

Please select your sex assigned at birth

Phone

Country

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State

Medical & Health Background

Height and Weight

Current Health Conditions

Please share any chronic health conditions or ongoing medical concerns to help us better understand your health needs.

Previous Surgeries and Procedures

Please list any previous surgeries or procedures, including the month and year they were performed.

Current Medications

Please list all medications you are currently taking, including frequency.

Allergies

Please list any known allergies, including medications, anesthesia, food, or environmental triggers.

Smoking and Alcohol Consumption

Please provide information about your smoking and alcohol use, including frequency, duration, and any relevant details about past or current habits.

Procedure-Specific Information

Doctor

Please select the doctor you would like to work with from the dropdown menu. This helps us ensure you're matched with the right specialist for your needs.

Desired Procedure(s)

Reason for Procedure

Please specify the reason for the procedure, such as aesthetic, medical, or other purposes.

Specific Areas of Concern

Please specify the areas of concern related to your procedure. For example, if it’s liposuction, mention areas like the abdomen, thighs, or other specific regions.

Preferred Timeframe for Surgery

Please select your preferred timeframe for surgery by choosing a quarter (e.g., Q1: January-March, Q2: April-June) to help us align with your schedule.

Q1 First Quarter (January, February, March)

Q2 Second Quarter (April, May June)

Q3 Third Quarter (July, August, September)

Q4 Fourth Quarter (October, Nobember, Decemeber)

Communication Preferences and Client Comments

Preferred Communication Method

Please select your preferred method of communication.

How did you hear about us?

Comments

Please share any additional information or details that the doctor should know before your consultation.

Terms and Conditions

Thank you for choosing NAKD Health Group for your health and wellness needs. Please note that submitting a consultation form is the first step in scheduling a consultation with our healthcare professionals. However, this does not automatically confirm your consultation.

I agree to NA-KD Health Group terms and Conditions | By completing this form, you are permitting us to follow up by phone, email, or text, and you agree to receive marketing materials related to our services.

Read More about our Terms and Conditions