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Consultation Questionnaire Form
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Consultation Questionnaire Form
CONSULTATION QUESTIONNAIRE
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?
Yes
No
Are they agreeable?
Yes
No
Do you understand that the objective of any cosmetic operation is improvement in appearance, not perfection?
Yes
No
Are you aware that the results of the operation might not fully meet your expectations?
Yes
No
Have you had any previous cosmetic surgery?
Yes
No
When, and what was done?
Who performed the surgery?
Where was it performed?
Were you satisfied with the results?
If not, why?
Submit