Consultation Form | Facial Surgery

Patient Information

Facial Surgery Procedures

Please mark which procedure(s) you are interested in. *
Please attach your photos below for the sugeons review. It is very important the surgeon has clear photos of the areas in order to give you an accurate consultation. Please review the sample pictures so you know what views we need. Max. File Size: 1 MB Per Picture

 

 

 

 
Compression Garments: We will need some measurements to provide you with the right garments after your surgery. *(For Chin Enhancement and Facelift procedures only)

Others Question & Medical History

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Medical History

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Do you have any allergies to medications?
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Do you currently have any problems in the following areas?
                                                                         If yes, please explain:
Do you have any allergies to medications?
 
General / Constitutional (fever, weight loss, other)
 
Do you have any allergies to medications?
 
Ears, Nose, and Throat (cold, sinus, chronic cough)
 
Cardiovascular (heart, vessels, etc.)
 
Respiratory (asthma, emphysema, etc.)
 
Gastrointestinal (ulcers, intestinal disease, etc.)
 
Genital, Kidney, Bladder
 
Skin (rosacea, skin cancer, psoriasis, etc.)
 
Neurological (MS, stroke, seizures, etc.)
 
Psychiatric (anxiety, depression, etc.)
 
Endocrine (diabetes, thyroid, etc.)
 
Blood / Lymph (bleeding disorder, high cholesterol, anemia, etc.)
 
Allergic / Immunologic (lupus, hay fever, rheumatoid arthritis, etc.)
 

Social History

Do you smoke?
Do you drink alcohol?
Do you exercise?