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All information is strictly confidential and utilised only for medical reference and record purposes. Please complete as accurately as possible as your safety and wellbeing is priority to us.
Surname:
Middle Name:
Name:
Please indicate if alternate names are used for confidentiality purposes and due to high profile exclusivity. For our Records Only
Email:
Date of birth:
Postal Address:
Suburb:
Country:
Zip/Postal code:
Telephone numbers (please include international and local area codes) At least one.

Intl. codeLocal Area codenumberpreferred
work
home
mobile
fax
  Please indicate preferential contact number
Emergency contact Surname:
Emergency contact Name:
Emergency contact number (please include international and local area codes)
         Intl. codeLocal codenumber

We may need to discuss certain issues with your GP

Does your GP know that you are considering procedure/s? Yes     No
Would you prefer us not to consult with your GP? Yes     No
Family physician/GP name
physical address
telephone
email address

Please specify which procedure/s you are considering
At least one procedure must be marked.
Surgical
Breast Augmentation:
Breast Lift (Mastopexy):
Breast Augmentation & Breast Lift:
Breast Reduction:
Inverted Nipple Correction:
Male Breast Reduction:
Face Lift / Neck Lift:
Brow Lift - Forehead:
Eyelid Surgery (blepharoplasty):
Rhinoplasty:
Ear Surgery:
Chin Augmentation:
Arm Reduction (Brachioplasty):
Liposuction:
Tummy Tuck:
Thighplasty:
Calf Augmentation:
Additional procedures not listed:
Please supply digital photos of selected area/s
Please provide two photos of area/s of procedures considered. One front view, and one side view.

Digital photos can be emailed to us or conventional photos can be couriered to our postal address.

We will confirm receipt thereof, please advise us of postage dates in order for us to confrim receipt.

If notification is not received within 5 days please advise as photos have not been received due to data transfer failure.
Additional procedures not listed
Non-surgical
Botox:
Perlane:
Restylane:
Lip Augmentation:
Additional procedures not listed
Dentistry
Veneers
Bleaching
Implants
Bridges
Crowning

Medical Information


We may ask for additional information as required by the surgeon
Age:
Height:
Weight:
Marital Status:
Social Security Number: (For US citizens only)
Male or Female Male     Female
Do you currenlty have or have you previously had any of the following?
AIDS or HIV not sure     yes     no
arthritis not sure     yes     no
asthma not sure     yes     no
back problems not sure     yes     no
colitis not sure     yes     no
diabetes not sure     yes     no
ear problems not sure     yes     no
eye problems not sure     yes     no
epilepsy not sure     yes     no
heart problems not sure     yes     no
heart murmur not sure     yes     no
Are you pregnant? not sure     yes     no
If so, please indicate how far along
Are you lactating? not sure     yes     no
Transfusion not sure     yes     no

Do you suffer from

osteoporosis not sure     yes     no
heart palpitations not sure     yes     no
hepatitis not sure     yes     no
high blood pressure not sure     yes     no
irregular heart beat not sure     yes     no
kidney problems not sure     yes     no
migraine headaches not sure     yes     no
nervous breakdown not sure     yes     no
nose/throat problems not sure     yes     no
pneumonia not sure     yes     no
blood clots in legs not sure     yes     no
blood disorders not sure     yes     no
bleeding problems not sure     yes     no
breathing problems not sure     yes     no
cancer not sure     yes     no
chest pains not sure     yes     no
psychiatric condition not sure     yes     no
rheumatic fever not sure     yes     no
seizures not sure     yes     no
shortness of breath not sure     yes     no
skin cancer not sure     yes     no
stomach problems not sure     yes     no
depression not sure     yes     no
stroke not sure     yes     no
thyroid problems not sure     yes     no

PAST, FAMILY, and HISTORY

Please list any prior hospitalizations and/or pervious surgery, including dates
Are you allergic or have you ever had a reaction to any medication or drug, local or general anaesthetic? not sure     yes     no
If so, please list medication and type of reaction
Are you currently taking or have you previously taken any regular medication
(aspirin, birth control pills, prescribed medications, herbs, vitamins etc.)?		 not sure     yes     no
currently taking
previously taken
Do you wear glasses or contact lenses? not sure     yes     no
Current prescription?
Do you have problems with dry eyes? not sure     yes     no
Do you use wetting drops? not sure     yes     no
If YES, how often, and for how long have you been using them?
Are you currently taking or have you previously taken a prescription or over-the-counter medication for allergies, stuffiness, difficulty breathing, sinus problems or other nasal problems? not sure     yes     no
If YES, Please list:
Do you currently smoke? yes     no
If YES, how many cigarettes per day?
If YES, for how long?
Have you ever smoked? yes     no
If YES, how many cigarettes per day?
If YES, for how long?
Do you drink alcohol regularly? yes     no
Have any of your relatives had breast cancer? not sure     yes     no
Have you ever had a mammogram? yes     no
If YES, when was your last one?

Have you had exposure to any of the following?:

radiation not sure     yes     no
excessive sun not sure     yes     no
Do you or any family members have difficulty with prolonged bleeding when cut? not sure     yes     no
Do you or any family members bruise easily? not sure     yes     no
Do you have a problem with excessive scarring or keloid formation after being cut? not sure     yes     no
Have you or any family members ever had a problem with anaesthetic? not sure     yes     no
Is your general health good? not sure     yes     no
Have you ever had psychiatric problems, a nervous breakdown or been under the care of a psychiatrist, psychologist or mental health counselor? not sure     yes     no
Is there any reason why you would not accept a blood transfusion? not sure     yes     no
We appreciate your time and thank you for completing our patient history and personal details form. Your health is of utmost concern to us. Our medical coordinator will review your information and contact you about your requirements as soon as possible.
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