Lipo Eligibility Test

This questionnaire determines your eligibility for liposuction.

1. Do you want liposuction to lose weight? *


2. Do you want liposuction to get rid of cellulite? *


3. What is your Body Mass Index (BMI)?
( *

4. What part of your body concerns you? *

Medical & Surgical History

Please describe your past medical and surgical history.

5. Considering the body area where you want liposuction, have you had, or do you have any of the following on this same area? *

Previous LiposuctionCool SculptingPrior surgeryA visible scarNone of theseOther

6. At the Liposuction Center, we do not perform liposuction on individuals with medical conditions that increase their risk of complications or death. These conditions include, but are not limited to:

Lupus; Severe Anemia; Eating Disorder; HIV; Hepatitis C; Hyperthyroidism; Bleeding Disorders; Scleroderma; Active Cancer; Heart Failure; Previous Bariatric Surgery

Yes, I have one or more of the above conditionsTo the best of my knowledge, I do not have any of the above conditions