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.