(303) 744-1202f
Fax: (303) 744-0418
Liposculpture Questionnaire


Name:
Street Address:
City: State: Zip:
Business Phone: Home Phone: Cell Phone: Fax:
Age: Sex: Male Female Married Divorced Widowed Single

Which body areas would you be interested in treating with liposculpture? Check all applicable boxes
  • Clicking on "view photos" will take you to a section where you can view photos
    organized by age, sex, and body area.

  • Skin Tone: Firm Moderately Firm Flabby Wrinkled Soft

    Cellulite (Dimples in Skin on Thighs and Buttocks): None A Few Many

    Stretch Marks - Indicate Areas and Severity Abdomen Fresh (pink or red) Old (white) A Few Many
      Midriff(Above Naval) Fresh (pink or red) Old (white) A Few Many
      Hips Fresh (pink or red) Old (white) A Few Many
      Buttocks Fresh (pink or red) Old (white) A Few Many
      Thighs or Other Areas Fresh (pink or red) Old (white) A Few Many

    EXERCISE LEVEL
    Personal Trainer? Yes No
    Do you:
    Walk For Exercise? Not At All 1 to 2 days per week 3 to 5 days per week 6 to 7 days per week
    Run? Not At All 1 to 2 days per week 3 to 5 days per week 6 to 7 days per week
    Aerobics? Not At All 1 to 2 days per week 3 to 5 days per week 6 to 7 days per week
    Bike? Not At All 1 to 2 days per week 3 to 5 days per week 6 to 7 days per week
    Swim? Not At All 1 to 2 days per week 3 to 5 days per week 6 to 7 days per week
    Aquacise? Not At All 1 to 2 days per week 3 to 5 days per week 6 to 7 days per week
    Rowing Machine? Not At All 1 to 2 days per week 3 to 5 days per week 6 to 7 days per week
    Treadmill? Not At All 1 to 2 days per week 3 to 5 days per week 6 to 7 days per week
    Stairs or Stair Stepper? Not At All 1 to 2 days per week 3 to 5 days per week 6 to 7 days per week
    Stretching or Yoga? Not At All 1 to 2 days per week 3 to 5 days per week 6 to 7 days per week
    Lifting Weights? Not At All 1 to 2 days per week 3 to 5 days per week 6 to 7 days per week
    Other? Not At All 1 to 2 days per week 3 to 5 days per week 6 to 7 days per week

    Smoke? Yes No   Previous Liposuction? Yes No   Abdominal Surgery? Yes No
    Diet Pills? Yes No   Abdominal Scars? Yes No   Very Heavy at One Point in Your Life? Yes No

    For Prices Call (303)744-1202

    Could you come to Colorado for your Surgery? Yes No

    Which days would you be available for your surgery?
    Monday Tuesday Wednesday Thursday Friday

    Which months would you be available for surgery?
    January February March April May June
    July August September October November December

    Would you like a free virtual consulation?
     
    Would you like to mail photos to us for a free professional opinion letter? Send to:
    Colorado Dermatology Center
    950 East Harvard Avenue, Suite 630
    Denver, Colorado 80210

    If you click below, your personal information and questionnaire will be transmited to the Colorado Dermatology Center(by doing so, you give permission for us to contact you and release your right to privacy in this regard.)