Landing 1 – Modern Plastic Surgery – Modern Plastic Surgery

Please answer questions & submit photos for doctor evaluation

Name

Last Name

Phone

Famale Male

Date of Birth

Weight (lbs)

Height

Procedure of Interest

Do you have any medical conditions?

Do you take any medications?

Alergies

Have you ever had any blood clots/ blood clotting? If yes, please describe the situation and when it happened

Any procedures or surgeries in the last 3 months? (Yes/No) If YES, please specify.

Do you have butt shots/ injections?

Do you have Children?

Do you smoke or use any nicotine products?

Do you drink alcohol?

Other Substances, please specify.

Desired Surgery Date

Notes

Attach files

Best time to call (office hours 9am- 6pm, M-F)