Amara Bella Questionaire

Please fill in the following questions

*send as an email on separate document*

Questionnaire

Please answer all questions, openly and honestly . Do not omit any answers. Omitting answers will cause in the delay of your quote.

1.Full Name:

2.Age:

3.Date Of Birth: MM/DD/YYYY

4.Height:

5.Weight:

6.Personal Contact Number:

7.Instagram name? Do you use it for surgery purposes? We like to make posts for our clients when they are flying to their surgical destination and again on the morning of their surgery .

8.Do you already have your quote? If so, from which Doctor and for what procedures? We will need you to provide us with the email or whatsapp conversation containing the quote to verify with the doctor.(Optional)

9.Requested / Preferred Surgeon:

10.Requested Procedure(s):

11.Date (Estimate) you want procedures done:

12.Do you already have a surgery buddy ?

13.Is someone traveling with you ? Male or Female?

14.Which Airport are you Flying from?

15.How long can you stay in the country?:(Optional)

8-10 days

10-12 days

12-14 days

16.Have you have any previous cosmetic procedures?:

17.If so, what procedures have you had done?

18.Who was your doctor ?

19.When did you have your previous surgery ?

20.Have you had any medically necessary surgeries?:

Yes No

20.If so , what surgery had you have done ,what date was the surgery performed and what was the reason for the surgery ?

21.Do you or have you had any medical conditions, illnesses , or injuries?

22.Are you currently taking any medication (including birth control)?:

Yes No

23.If so, please provide the name of the medication.

24.Why were you prescribed this medication?

25.Do you have any allergies to medicine? If so, please list them .

26.If you have any allergies to food , please make sure you let the recovery home owner know upon arrival.

27.How many pregnancies have you had?

28.How many C-sections have you had?

29.How many vaginal deliveries have you had?(Optional)

30.Do you Smoke?

Yes No

31.If you smoke, please list what you smoke and how often/how many packs per day :(Optional)

32.Do you drink alcohol?

Yes No

33.If so , how often do you drink?(Optional)

Photo requirements

We will need 4 well lit photos of you from the front, back, and both sides . Photo must be in color with no clothing on (Doctors request) . Please crop out your face . If possibly please have someone else take the photos . The photos should be from your neck down to your ankles . The photos must be clear to avoid a delay in your quote retrieval process. Unfortunately if the photos are not acceptable , we will have to ask for new ones. Attach photos to an email with your name and Photos in the subject .

34.What email should we send the paypal invoice to ? Your information will be sent to the doctor of your choice after payment is received.

Important notice

Please answer all questions completely to avoid delaying your quote. We ask that you are honest with us , your doctor, and yourself. If any information is not correct your quote may change upon the doctors in person evaluation of you. All the information is absolutely critical to the successful outcome of your surgery. All information is 100% confidential . No information will be provided to anyone other than Amara Bella and the doctor and staff of your choice.

35.Please give us an emergency contact and phone number .

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