Patient Age
xx
Children
xxxx
Height & Weight
xx – xx
Breast Implants
xxxx
Pre-Op Bra Size
xxxx
Post-Op Bra Size
xxxx
DR HERTESS MEMBERSHIPS
Patient Age
xx
Children
xxxx
Height & Weight
xx – xx
Breast Implants
xxxx
Pre-Op Bra Size
xxxx
Post-Op Bra Size
xxxx