PRE SURGICAL EVALUATION FORM

Welcome To The Surgical Patient Evaluation Form.

Answer all questions as honestly as possible and do not omit any information.

Picture Submission

PLEASE USE THE GUIDELINES BELOW TO ENSURE THAT THE PHOTOS YOU SUBMIT ARE ACCEPTED BY ALL OUR DOCTORS AND SERVICE PROVIDERS.

BREAST SURGERY PHOTOS:
For clients requesting any type of Breast Surgery, the following additional requirements are needed for our surgeons to make a more informed decision on suitability as a candidate for surgery.

• The front view includes the neck, shoulders, breasts, and navel.

• Front view with both arms raised above the head.

• Front view with both arms raised above the head, body leaning or slightly bent forward assuming a diving position.

• Left and Right Side view with both arms down the side, as if standing to attention.

• Left and Right Side view with both arms raised above the head, body leaning forward or slightly bent forward assuming a diving position.

FACIAL  PHOTOS MUST INCLUDE:

• Left Profile

• Right Profile

• Front On

• Head Tilted Backwards

• Head Tilted Downwards

RHINOPLASTY PHOTOS MUST INCLUDE:

• Left Profile

• Right Profile

• Front On

• Head Tilted Backwards

• Head Tilted Downwards

TUMMY TUCK PHOTOS MUST INCLUDE:

• Left Profile

• Right Profile

• Front On

• Back On

THIGH LIFT PHOTOS MUST INCLUDE:

• Left Profile – Showing Inside Thigh

• Right Profile  – Showing Inside Thigh

• Left Profile – Showing Outside Thigh

• Right Profile  – Showing Outside Thigh

• Front On

• Back On

ARM  PHOTOS MUST INCLUDE:

• Left Arm Raised At Side Of Body

• Right Arm Raised At Side Of Body

 

Press this button if you understood each and every one of the instructions.