SURGICAL CONSULTPRE ASSESSMENT Name * First Name Last Name Email * Phone (###) ### #### What services are you interested in? Rhinoplasty Face / Neck lift Upper Blepheroplasty Lower Blepheroplasty Fat Transfer Brow Lift Chin Augmentation Lip Lift Buccal Fat Removal Desired Surgical Timeframe 1-3 Months 6 Months 1 Year How did you hear about us? Do you smoke Yes No Are you in the process of losing weight? Yes No What previous treatments have you had on your face and/or neck? Select all that apply Neuromodulators (Botox, Dysport, etc.) Hylaluronic acid fillers Sculptra Radiesse Ultherapy/Softwave Radiofrequency / Microneedling (Morpheus8, Vivace, etc.) Thermage Thread lifts Have you had any facial cosmetic surgery in the past?* YES NO Do you have any of the following medical conditions? Cardiovascular (heart) issues Pulmonary (lung) issues Bleeding or Clotting disorders High Blood Pressure Connective Tissue Disorders Autoimmune disease History of DVT or pulmonary embolism None of the above Please list any current medications. If you have none, type "none."* Please list any allergies (including antibiotics and anesthetic agents). If you have none, type "none."* Thank you!
