Liposuction Survey

Fill out this form to see if you qualify for LipoMassage™. Your information will be kept confidential.

Are you considering getting liposuction?	Yes No
If so, to what area(s) of your body?	Buttocks Thighs Hips Stomach Back Legs Other
Rate your level of interest in having liposuction done:	Just thinking about it and getting the facts first I am at least 50% sure I want to get liposuction I definitely plan to get liposuction
If you definitely plan to get liposuction, what is your approximate timeframe?	Within 2 weeks from now Within 4-6 weeks from now Within 2-6 months from now Over 6 months from now
List any concerns you may have about liposuction:	Safety issues Anesthesia It may make my fat look worse My fat may come back later I might have uneven contours afterwards Recovery time None
Would you like to receive a LipoMassage demo treatment?	Yes No
Would you like to receive a liposuction consultation with a cosmetic surgeon?	Yes No
Name:
Email Address:
Day time phone number where you can be reached: