| * ZIP/Postal Code |
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| * Country |
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| Phone |
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| Fax |
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| * Email |
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Website URL
(Please include http://www.) |
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| Languages Spoken |
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| Contact |
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Professional Information
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Speciality
Example: Plastic Surgery,
Cosmetic Surgery |
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| Procedures Performed |
Abdomen
Anterior Thighs
Arms
Back
Buttocks
Chin/Cheeks/Jowls
Fat Transplantation
Female Breast Reduction
Hips and Waist
Inner Thighs
Knees
Legs/Calves/Ankles
Male Breast Reduction
Males Flanks
Outer Thighs
Other
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| Medical License Number |
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| State Issuing Medical License Number |
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| Country Issuing Medical License Number |
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| Do you have malpractice insurance coverage for liposuction? |
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| (The Following Malpractice Insurance Information will not appear on your membership listing.) |
| Malpractice Insurance Company |
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| Malpractice Insurance Company Phone |
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| Malpractice Insurance Policy Number |
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| Have you ever been disciplined? |
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| If So, Please Explain |
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| Surgeon's Academic Affiliations |
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| Surgeon's Hospital Affiliations |
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| Professional Societies |
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| Are you board certified? |
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| Which medical board certified you? |
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| What year were you certified? |
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| Where did you go for medical school? |
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| What year did you graduate from medical school? |
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| Where did you get your undergraduate degree? |
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| What year did you get your undergraduate degree? |
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| What was your undergraduate degree? |
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| Where did you complete your postgraduate residency training? |
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| What year did you complete your postgraduate residency training? |
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| Post Graduate Clinical Fellowships |
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| Other Degrees |
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| Medical Academic Appointments |
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| Current Advanced Cardiac Life Support (ACLS) Certificate, American Heart Association or equivalent certificate? |
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Optional
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| Practice Information and Mission Statement |
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| Type of surgical facility used in majority of your liposuction cases |
Office Surgical Facility
Accredited Office Surgical Facility
State Licensed And/Or Medicate Approved Surgical Facility
Hospital
Other
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| Your preferred method for liposuction anesthesia |
Liposuction plus General Anesthesia
IV Anesthesia/Sedation (Conscious Sedation/Mac) and Tumescent Technique
IV Analgesia/Sedation and Tumescent Technique
Other
Oral Sedatives plus Tumescent Technique
Liposuction plus General Anesthesia + Tumescent Local Anesthesia
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| Types of liposuction cannulas and techniques you use |
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| Size of the Majority of Skin Incisions |
1 to 2 mm round holes
3 to 4 mm linear incisions
5 to 8 mm linear incisions
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| After-Liposuction Care -Technique |
Incisions Are Not Closed With Stitches (Open Drainage Technique)
Incisions Are Closed With Stitches
Some are closed and some are left open
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| The average length of time that your patients wear post-op elastic garments |
6 Days Or Less
7 to 13 Days
14 to 21 Days
More Than 21 Days
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Description of your liposuction procedure.
(max 250 words) |
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Biography of Surgeon
(max 250 words) |
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Articles Author/Subject
If you would like your articles made available to website visitors, please contact info@liposuction.com |
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Before & After Photographs of lipo patients treated by the surgeon. (Optional)
The publication of 4 sets (2 photos per
set) of “Before and After” photos is included with basic annual fee. For an additional fee, extra sets of “Before & After” photos can be published on liposuction.com and linked to the surgeons name. Digital photos (which are preferred) can be jpeg or tiff, and should be at least 200 pixels in width. Send as an email attachment to: support@liposuction.com.
Printed photographs are acceptable (there is no extra fee to scan and digitize photographs).
Please mail these photos separately to the following address:
Registration, Liposuction.com
1001 Avenida Pico
Suite C402
San Clemente, CA. 92673
Please note: Your 1 year period will not begin until you are actually online.
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| * Username |
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| * Password |
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