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  On Liposuction
  From Vermont Plastic Surgeons

• • 1. What parts of the body are you considering getting liposuction on?
  • Waist / Hips
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  • 2. Have you had liposuction before? Please explain.
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  • 3. How old are you? Please make a selection 18 or Under 19 - 25 26 - 30 31- 35 36 - 40 40 - 45 46 - 50 Over 50
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  • 4. How do you plan to pay for the surgery? Please make a selection Cash Credit Card Loan Gift Don' t know yet
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  • 5. How soon did you want to have the surgery? Please make a selection Less than 1 month 1-2 months 2-4 months 4 + months undecided
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  • 6. Gender? Male Female
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  • 7. Height?
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  • 8. Weight?
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  • 9. Do you have any existing medical conditions? Yes No
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  • 10. Do you have transportation to and from surgery? Yes No
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  • 11. Any additional information
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