Thank you for your interest in starting your surgical journey with us. Submitting this form allows Dr. Miotto to review your medical information and determine whether surgery is a safe and appropriate option to help you achieve your goals. There is no charge to submit this form.
After submission, our coordinators will reach out to guide you through the next steps and answer any questions you may have. Your formal consultation with Dr. Miotto has a $500 consultation fee, which will be fully credited toward your surgical procedure once surgery is booked.
Preferred contact method* Select an option Text Phone Call Email
How did you hear about Dr. Miotto* Select an option Facebook Google Instagram Patient Referral Physician Referral Real Self Artificial Intelligence (AI) Other
Please clarify
Referral Name
Procedure(s) of interest (select all that apply) Please clarify
Please clarify
Height* Select your height 4ft 0in 4ft 1in 4ft 2in 4ft 3in 4ft 4in 4ft 5in 4ft 6in 4ft 7in 4ft 8in 4ft 9in 4ft 10in 4ft 11in 5ft 0in 5ft 1in 5ft 2in 5ft 3in 5ft 4in 5ft 5in 5ft 6in 5ft 7in 5ft 8in 5ft 9in 5ft 10in 5ft 11in 6ft 0in 6ft 1in 6ft 2in 6ft 3in 6ft 4in 6ft 5in 6ft 6in 6ft 7in 6ft 8in 6ft 9in 6ft 10in 6ft 11in
Your BMI:
How many pounds are you from your goal weight?* Select an option At my goal weight 10 Pounds 20 Pounds 30 Pounds 40 Pounds ≥ 50 Pounds
Are you currently taking Ozempic, Mounjaro, Wegovy or any other semaglutide for weight loss?* Select an option Yes No
Medical History (For your medical safety, please select all past or current conditions that apply to you) * Cancer Diabetes Heart Disease High Blood Pressure Blood Clotting (Deep Vein Thrombosis, Pulmonary Embolism, etc) Organ Transplants Respiratory Disease Other None
What is your most recent A1C level (%)? 5.9% or below 6.0% - 6.4% 6.5% - 6.9% 7.0% - 7.4% 7.5% - 7.9% 8.0% or higher Unsure / No test in the last 6 months Please clarify
Do you smoke, vape or use any nicotine products?* Select an option Yes, I currently smoke, vape, or use nicotine products. Yes, I occasionally smoke, vape, or use nicotine products. No, I do not currently smoke, vape, or use nicotine products and quit over 1 year ago. No, I have never smoked, vaped, or used nicotine products.
Please clarify
What is your timeframe for Surgery?* Select an option Within 3 Months 3-6 Months 6-12 Months Just gathering initial information
Did you experience any complications from these procedures?* Select an option Yes No
Please explain
Are you pleased with your previous plastic surgery or aesthetic procedures?
For your medical safety, which of the following treatments have you previously had on your face, eyes, or neck? Botox / Dysport (Neuromodulators) Hyaluronic Acid Fillers Radiesse Sculptra Ultherapy Threadlift Morpheous Sofwave How long ago? Under 6 months ago 6–12 months ago Over 1 year ago How long ago? Under 6 months ago 6–12 months ago Over 1 year ago How long ago? Under 6 months ago 6–12 months ago Over 1 year ago How long ago? Under 6 months ago 6–12 months ago Over 1 year ago How long ago? Under 6 months ago 6–12 months ago Over 1 year ago How long ago? Under 6 months ago 6–12 months ago Over 1 year ago How long ago? Under 6 months ago 6–12 months ago Over 1 year ago How long ago? Under 6 months ago 6–12 months ago Over 1 year ago
* Please submit 3 clear, facial photographs in JPG or PNG format with the total file size under 5MB.
