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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.

 
Legal Name *
Preferred Name or Nickname *
Date of Birth (MM/DD/YYYY) *
E-mail *
Telephone *
Zip Code *
Do you already have a surgical consultation scheduled? *
Type of consultation preferred *
If you selected Video Call, which platform do you prefer? *
Please let us know how you heard about us! *
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, please let us know who your insurance carrier is and upload photos of your insurance card. *
Insurance Card photos (front and back). *
Please avoid spaces or special characters (# % & { } \ < > * ? / $ ! '" : @) in the name of file.
Lastly, please upload unaltered, high-resolution photos that clearly show your area(s) of concern.
Use the above "browse" button to upload files. To select multiple files, use the Control (Windows) or Command (Mac) and click on each file you'd like to upload prior to clicking "Add". To select multiple photos from a mobile device, please select all photos prior to clicking "Add". Once you click Add, you will not be able to upload more photos on the same form. If you accidentally click Add and want to add more photos, please remove the photo then re-add them. Limit: 8MB
Photos of area(s) of concern. *
Please avoid spaces or special characters (# % & { } \ < > * ? / $ ! '" : @) in the name of the images.
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 photos, 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).
Take photos in the following orientations: facing the camera, at 45-degress (3/4 view), 90-degrees (side view). For body liposuction with your back facing the camera. For Rhinoplasty/Septoplasty (nose surgery), the bottom of the nose (view of nostrils) is an important angle. We do need all angles to appropriately assess you.
(Optional) For fat transfers, please provide your height and weight. For liposuction or abdominoplasty (tummy tuck), please provide your waist and hip measurements.
 
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