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Surgical Consultation intake form

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 *

When were you born (MM/DD/YYYY)? *

E-mail *

Telephone *

Zip Code *

Do you already have a surgical consultation scheduled? *

Type of consultation preferred *

In-person Consultation
Video Call (Google Meet) with Photo Review
Phone Call with Photo Review
E-mail response with Photo Review

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. *

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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