Application for Plastic Surgery

    Have you received any treatment with us before?* YesNo

    Birth Date*

    Do you take any medications/drugs?* YesNo
    Do you take, or have you take in the past Blood-thinners?* YesNo
    Penicillin* YesNo
    Sulfa Drugs* YesNo
    Iodine* YesNo
    Tape* YesNo
    Latex* YesNo
    Aspirin* YesNo
    High lipid levels* YesNo

    Previous Bariatric Surgery*

    Date of surgery*

    Have you ever had a problem with an anesthetic?* YesNo
    Do you smoke cigarettes?* YesNo
    Do you drink alcohol?* YesNo
    Use recreational drugs?* YesNo
    Are you easy fatigued?* YesNo
    Do you have shortness of breath?* YesNo
    Do you have asthma?* YesNo
    Stroke* YesNo
    Diabetes* YesNo
    Coronary Artery Disease* YesNo
    Liver disease* YesNo
    Lung disease* YesNo
    Renal disease* YesNo
    Thyroid disease* YesNo
    Hypertension* YesNo
    Any other illnesses* YesNo

    Date of last menstrual period*

    Do you use any type of birth control?* YesNo

    Birth Control*

    Are you presently, or have you ever taken hormones?* YesNo
    Are you presently, or is there a possibility of you being pregnant?* YesNo
    Have you had any previous surgery?* YesNo

    Previous Surgery

    Do you use or B-PAP while your sleep?* YesNo
    Do you exercise?* YesNo


    When are you planning on having surgery?*

    Photographs: Completely Naked so doctors can have a clear view of surgical areas for evaluation.
    Left side*
    Right side*

    • For your evaluation this info must be submitted. The surgeons will evaluate your case based on a overall individualized cased. Surgical plan can be changed upon consult face to face evaluation.