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2023-02-11T09:33:31+00:00
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You will receive a customized quote within three business days!
First name
*
Last name
*
Email
*
Phone number
*
Date of Birth
*
Weight
*
Height
*
Tentative Travel Date
*
City & State
*
Promo Code
Do you have a valid Passport?
*
Yes
No
Payment Option
*
One Time Payment
Layaway
Financing
How did you hear about us?
*
Social Media
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Smiley Aesthetics (Please Provide the name)
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Smiley Aesthetics
Name of the person who referred you
Readiness Status
*
Ready to Book
Getting Quotes
Would you be traveling alone?
*
Yes
No
Have you been hospitalized in the last 12 months?
Yes
No
Are you suffering from a medical condition, illness, allergies or injury?
*
Yes
No
How many pregnancies have you had?
*
0
1+
3+
Do you smoke?
*
Yes
No
How many surgeries have you had?
*
0
1+
3+
If you answered Yes to any question, please elaborate on surgeries, conditions and hospitalizations. Please write N/A if you answered No.
*
What procedure are you interested in?
Gastric Sleeve
Gastric Bypass
Add-Ons
Cosmetic Procedure (Please specify in the comments section)
Dental Procedure (Please specify in the comments section)
Compression Girdle (Faja)
Body Contouring Massages (Atlanta)
Tourism- Bogota City Tour
Tourism- Salt Cathedral of Zipaquirá and Nemocón mine
Tourism- Villa de Leyva Tour
Tourism- Coffee Farm
Other (Please specify in the comments section)
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Questions & Comments
Terms and Condition
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I declare that the info I’ve provided is accurate & complete. I read & agree to the Medical Release Authorization Terms .
By submitting this form, you consent to Smiley/ My Body by Design LLC and the clinic's medical team to use of your data contained in this questionnaire for purposes limited to medical use only. Smiley/My Body by Design takes no responsibility if you provide false information or conceal your entire medical history. I understand that my personal information will be treated separately and confidentially. I declare that the info I’ve provided is accurate & complete.
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