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Full Name *

First Last

Email Address *

(e.g john@doe.com)

Telephone Number*

Do You Reside Inside Of USA?*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Country*

Have you had a consultation with Goals Plastic Surgery within the last 12 months?*

YesNo

Which procedure or service are you most interested in?*

Please briefly describe what you would like to achieve through the procedure(s) selected above. *

What is your desired timeframe for the procedure you selected?

Less than 1 Month1 to 3 Months3 to 6 Months6 Months or More

Will you be able to visit one of our locations for an in-office consultation? (This is greatly encouraged for patients located in New York and New Jersey)

Yes, I will be able to visit one of Goals locations.No, I will not be able to visit a location for my consultation.

Which of our locations would you like to visit for your consultation?

HarlemBrooklynAtlanta

Do You Need Financing?*

What Is Your Family Household Income?

What Is Your SSN?

For Credit Verification Purposes

What is your Instagram? *

(e.g @johndoe)

Gender*

What is Your Height & Weight?*

BMI Result

Date of Birth*

Date

Are you in good health? *

YesNo

If not, please explain.

Are you pregnant?*

YesNo

Are you currently under the care of a physician?*

YesNo

Have you been hospitalized or had a serious illness within the last five (5) years? *

YesNo

If so, please explain.

Have you ever had any prior cosmetic procedures (Botox, Fillers, etc), Breast Augmentation/Reduction, Liposuction, Tummy Tuck, or other cosmetic surgery?*

YesNo

If so, please explain.

Have you previously experienced weight loss of 70 pounds or more in the past 2 years?*

YesNo

If so, please explain.

Do you have, or have you had, any of the following diseases or problems?*

Do you have allergies to any medications?*

YesNo

Please list all the medication(s) you may be allergic to.

Do you have any food allergies?*

YesNo

Please list all the food(s) you may be allergic to.

Are you currently, or have you previously, been prescribed any psychiatric medication(s)?*

YesNo

If so, please explain.

Are you allergic or have you reacted adversely in any way to the following?*

Do you drink alcoholic beverages? *

NeverSociallySometimesAlways

Do you consume ANY tobacco products?*

NeverSociallyDaily

Are you taking any drug or medication, prescription, or non-prescription?*

YesNo

If so, please list.

Are you taking any of the following?*

Do you have any disease, condition or problem not listed that you think the doctor and office should be aware of or know about?*

YesNo

If so, please explain.

Front View Shot*

Please take a photo that provides a front view.

Right Side View*

Please take a photo that provides a right side view.

Left Side View*

Please take a photo that provides a left side view.

Rear View Shot*

Please take a photo that provides a rear view.

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

You are not required to take this Notice and you may return it to us if you wish. However, as a patient, you are asked to acknowledge receipt of the Notice by signing this Acknowledgement of Receipt of Notice of Privacy Practices (“Acknowledgement”).

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), we are required to furnish you with a copy of the Notice and make it available to you for subsequent inspection. We are also required to provide this Acknowledgement for your signature. This Acknowledgement does not contain the Notice, it only confirms that you have received the Notice. You are not required to sign this Acknowledgement, though we are required to note in our files any refusal you might indicate to sign this Acknowledgement.

PATIENT ACKNOWLEDGMENT

• I have received and reviewed NYC Medical Practice, P.C. d/b/a Goals Plastic Surgery’s Notice of Privacy Practices, which is written in plain language and contains a detailed explanation of:

- Uses and disclosures of my personal health information by NYC Medical Practice, P.C. d/b/a Goals Plastic Surgery;
- My individual rights with regard to those disclosures; and
- My choices regarding how my health information is used and shared.

• I understand that I am entitled to keep the copy of the Notice of Privacy Practices that was provided to me.

CONSENT FOR EVALUATION AND/OR TREATMENT

By signing below, I am giving my consent to NYC Medical Practice, P.C. d/b/a Goals Plastic Surgery for evaluation and/or treatment. Once I have been examined, I understand that I will be informed of any medical or cosmetic recommended procedures and/or treatments and given the option to accept or decline.

I certify that all the above information is accurate to my knowledge.*

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