Consultation Questionnaire Form

Please give your contact details

Name:

Email:

In which surgical procedure(s) are you interested? (Please check)

Face

Entire Face

Mid Face

Lower Face

Skin Resurfacing

Nose

Chin

Brow

Eyes

Lips

Neck

Body

Liposuction

Thigh Lift

Arm Lift

Abdominoplasty

Scar Revision

Protruding Ears

Breast

Breast Augmentation

Breast Lift

Breast Reduction

Other Procedure

What specifically do you wish to have corrected (i.e. what don’t you like about the above condition(s)

When did you begin to consider surgical correction?

What is most important to you in your cosmetic surgery procedure?

Why have you decided to have it done at this point in time?

Have you consulted any other doctor about this? (When?)

Have you discussed this surgery with your family?

YesNo

Are they agreeable?

YesNo

Do you understand that the objective of any cosmetic operation is improvement in appearance, not perfection?

YesNo

Are you aware that the results of the operation might not fully meet your expectations?

YesNo

Have you had any previous cosmetic surgery?

YesNo

When, and what was done?

Who performed the surgery?

Where was it performed?

Were you satisfied with the results?

If not, why?

CONSULTATION QUESTIONNAIRE

Face

Body

Breast

Schedule Consultation