Date of Birth/Age*
What procedure(s) are you interested in?
Do you have any medical problems? Please List them.
Have you had any previous surgeries? Please List them.
What medications do you take on a daily basis?
Do you smoke?
Yes NoIf yes, how much and for how many years.
Are you interested in having any other procedures at the same time?
No Yes, Liposuction Yes, Tummy Tuck Yes, Facial Surgery Yes, Botox and/or Fillers Yes, Other
If interested in other procedure, please explain:
When do you want to have the surgery?
Less than one month 1 to 3 months more than 3 months from now
How do you plan to pay for the procedure?
Cash Check Credit Card Apply for Financing
How many children have you had?
1 2 3 4 5 or more
Did you breast feed?
Yes NoIf yes, for how long on average.
Do you plan on having children in the future?
Yes NoIf yes, when?
Have you had any problems with your breasts (such as cysts, lumps, abnormal discharge, skin changes, etc)?
Yes No If yes, please list:
Have any close relatives had breast cancer?
The last mammogram I had was:
never had one less than one year ago more than one year ago
What procedure are you interested in?
Breast Augmentation Breast Augmentation with Lift Not sure if I need a lift Breast Lift Only Replace Implants I already have Replace Implants I already have and a Lift Remove Implants I have with a Lift
What type of implants are you interested in?
Saline Silicone Gel Not Sure
What Bra size do you currently wear?
32 34 36 38 40 A B C D DD
What cup size do you want to be after surgery (approximate)?
A B C D DD
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