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Surgical Consultation intake form

In advance of your upcoming surgical consultation, we would like to gather some preliminary to ensure you receive the most benefit out of your time with the doctor.

Please answer the below questions as fully as possible.

Also, it is important that you send us images of sufficient quality so that we can adequately assess your cosmetic concerns. Please review the General Photo Taking Guidelines at the bottom of this form prior to uploading photos or for a visual of the types of photos we need, please see these tips on taking photos.

 
Name *
Date of Birth (MM/DD/YYYY) *
E-mail *
Telephone *
Do you already have a surgical consultation scheduled? *
Type of consultation preferred *
If you selected Video Call, which platform do you prefer? *
Please share in detail the areas of concern you would like to discuss with the doctor. *
Have you had previous surgeries or non-surgical treatments in or around the areas of your concern within the past 6 months? If yes, what were they? *
Have you had other cosmetic surgeries in the past? If yes, what where they and approximately when did they take place? *
If you are coming in for Rhinoplasty/Septoplasty (nose surgery) or another potentially medical-related reason, who is your insurance carrier? And please upload photos of your insurance card (front and back) *
Lastly, how did you hear about us? *
Use the below "browse" button to upload photos you want to share with us. To select multiple images, use the Control (Windows) or Command (Mac) and click on each file you'd like to upload. Limit: 8MB
Upload Photos that show your area(s) of concern. At a minimum submit front view and views form each side. *
General Photo Taking Guidelines
Have another person take your photos or use a camera timer. We do not accept selfies (handheld or on a selfie stick) as they are taken from too close of a distance that often distorts proportions. Use a solid color background without any objects (a plain wall works great). For face/neck, make sure eyeglasses are off and hair is pulled away from the face as much as possible. Orient the camera vertically so that the framed picture is a vertical rectangle (higher up/down than side/side) instead of a horizontal rectangle. Take photos facing the camera straight-on, at 45-degrees (3/4 view), 90-degrees (side-view), and for liposuction with your back facing the camera. For Rhinoplasty, the bottom of the nose (view of the nostrils) is an important angle. (Optional) For breast augmentation, lift, or reduction, please send us your under breast measurement. (Optional) For liposuction or abdominoplasty (tummy tuck), please send us a measurement of your waist and hips.
 
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