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Global Waitlist ✧ Aurelia

Website: withaurelia.com

✋ This form is for individuals 18 years or older. Please do not submit if you are a minor. 🔒 This is not a medical intake form. We do not collect medical history. Your information is secure.

Name

*

Email

*

Which procedure are you planning?

*

Which procedure are you planning?

1

Non-Surgical (e.g., Botox, Thermage, Rejuran, Juvelook)

2

Tummy Tuck (Abdominoplasty)

3

Body Contour / Liposuction

4

Brazilian Butt Lift (BBL)

5

Breast Augmentation / Implants

6

Rhinoplasty (nose job)

7

Facelift / Neck Lift

8

Mommy Makeover

9

Hair Transplant

10

Just researching

11

Other

When are you hoping to have this procedure?

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When are you hoping to have this procedure?

A

0-3 months

B

3-6 months

C

6–12 months

D

Just researching

E

Other

Anything else you want to share?

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I understand this is not a medical intake form and I'm okay receiving occasional Aurelia updates.

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