Consultation Form | Breast Surgery

Patient Information

Breast Surgery Procedures

Please mark which procedure(s) you are interested in. *
Breast Measurements
In order for your surgeon to determine the correct size implant he will need the following measurements.
V Section to Nipples:
The "V" is the notch in your breastplate, between your collarbones and approximately 3 inches below your adams apple.
Please measure from the middle of each nipple to your mammory fold. (the crease where your breast meet your chest)
8-Cup Size
 What cup size are you now:What cup size you would like to be:
Cup Size
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

 

 

 

 

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?