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Application for Plastic Surgery

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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.

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