Magic Post Op - Client Consent + Intake

Section 1 of 4

1 of 24 required fields complete (4%)

Section 1

Media Release Agreement

Choose how you want to participate in photo or video content.

Email Address* (required)Required

Media Release Agreement*RequiredI give permission for MJS to use my photos/videos, including my name, face, voice, and likeness for advertising and promotional purposesI give permission but prefer to remain ANONYMOUSI do not wish to participate in the media content at all (this includes any photos, videos, or voice recordings)

Section 2

Client Consent + Waiver

Participant demographics and contact details.

Last Name* (required)Required

First Name* (required)Required

Middle Initial(optional)

Address

Where can your care team reach you by mail?

Address* (required)Required

City* (required)Required

State* (required)Required

Zip Code* (required)Required

Phone numbers

Cell phone is required. The rest are optional.

Home Phone(optional)

Work Phone(optional)

Cell Phone* (required)Required

Fax(optional)

Email* (required)Required

Used for appointment confirmations

Date of Birth* (required)Required

MM/DD/YYYY

Company Name(optional)

Occupation(optional)

Section 3

Client Intake

Tell us about your surgery, recovery setup, and goals.

Full Name* (required)Required

Surgery details

What was done, where, and when?

Name of Plastic Surgeon* (required)Required

Name of Facility* (required)Required

Date of Operation* (required)Required

MM / DD / YYYY

Surgery Location*RequiredDomesticForeign

Operations Performed*Required

LipoLipo 360Arm LipoThigh LipoBack LipoBreast AugmentationBreast ReductionBreast LiftChin LipoFat TransferTummy Tuck / Abdominoplasty360 Tummy TuckBBLMammoplastyBrachioplastyThighplastyCesarean (C)-sectionHysterectomy / OophorectomyMastectomyOrgan removal surgery / ViscerectomyLaser procedureHernia RepairOther

Stayed at Recovery Facility*RequiredYesNo

Future Procedures Scheduled(optional)

If so, please specify the procedure and the date scheduled.

Current Discomfort Level (1 to 10)(optional)

12345678910

1 = no discomfort, 10 = severe

Current Medications* (required)Required

List name and dose. Write 'None' if none.

Bowel Movements*RequiredNormalIrregularConstipated

Hydration Levels*RequiredLess than 1 liter1 to 2 litersA gallon

Post-Op Supplies(optional)

FajasFoam boardsWaist trainerCompression SocksSideboardsOther

Post-Op Recovery Goals(optional)

Reduced scar tissueLess bloatingDefinitionBody sculpting and contourOther

Section 4

Acknowledgement + Signature

Confirm and sign electronically.

Participant Name* (required)Required

Type your full legal name

Date* (required)Required

MM / DD / YYYY

Participant Signature* (required)Required

Sign with your mouse, trackpad, or finger - or use the typed signature option below.

Use your finger on touch screens or your mouse on desktop.