BEVERLY HILLS | LOS ANGELES

9735 Wilshire Blvd, Suite 330
Beverly Hills, CA 90212

CALL NOW
310-858-8808

Online Consultation Form Beverly Hills

Online Plastic Surgery Consultation Request

Please “Click here” to Download the form, fill it and fax it to 310-858-8818, or fill it out below.

Fill out form:

An online consultation is available for those patients who live outside of the Los Angeles area or who are otherwise unable to come to our office in Beverly Hills. The online consultation consists of several steps that are designed to determine the very best options available to achieve your desired goals including a thorough questionnaire and submission of pictures.

You will be given the same superior level of attention and care that you would experience if you came to the office.

All questions must be answered before the form can be submitted.

Full Name (required)

Today's Date (MM-DD-YYYY)
--

Birth Date (MM-DD-YYYY)
--

Age

Sex

Marital Status

Street Address

City

State

Zip Code

Best Phone Number to Reach You: (circle) Mobile -Home- Work (required)

Other Number: (circle) Mobile Home Work

Email (required)

Occupation:

Employer:

Health Insurance Provider:

ID Number:

Name of Primary MD:

Telephone Number:

In Case of Emergency, Who Should We Contact:

Relationship:

What is their telephone?

 

Consultation Information

What procedure(s) are you interested in?

Explain the things that are bothering you and what you hope surgery will accomplish:

 

Medical History

Do you have or have you ever had any of the following?

 

High Blood Pressure
YesNo

Cancer
YesNo

Heart Trouble/Attacks
YesNo

Kidney Problems
YesNo

Difficulty walking 2 blocks
YesNo

Ulcer/Heartburn
YesNo

Heart Murmurs
YesNo

Eye Diseases
YesNo

Heart Palpitations
YesNo

Dry Eyes
YesNo

Irregular Heart Beat
YesNo

Thyroid Problem
YesNo

Chest Pains
YesNo

Asthma
YesNo

Shortness of Breath
YesNo

Anemia
YesNo

Swelling of Ankles
YesNo

Blood Disorders
YesNo

Rheumatic Fever
YesNo

Skin Disorders
YesNo

Herpes “Fever Blisters”
YesNo

Easy bruising
YesNo

Asthma
YesNo

Prolonged bleeding with dental work or cuts
YesNo

Chronic Lung Problems
YesNo

Problems with scars/keloids
YesNo

Diabetes
YesNo

Any other serious illnesses?
YesNo

Please explain

Women: Number of pregnancies:

Number of births:

 

Anesthesia

Have you or any family members had a problem with general anesthesia?
YesNo

Have you had any allergic reactions to lidocaine, epinephrine or local anesthesia or problems with numbing agents during dental work?
YesNo

Height:

Weight:

Medications: What medications are you currently taking? (please include herbals and vitamins)

List any medications taken in the last 6 months

Allergies to medication

Hospitalizations or prior surgeries, please list with dates

Do any diseases run in your family? Please list

Are you under the care of psychiatrist, now or ever?
YesNo

Do you smoke? If yes, how much? else specify no

Have you ever smoked? If yes, when did you quit? else specify no

Do you drink? If yes, how much? else specify no

Previous drug use?
NoYes


If you are considering breast surgery, have you had a mammogram?
NoYes


When was your last mammogram?

What was the result?

I attest that everything I have completed in this questionnaire is accurate and correct. I understand that not disclosing medical information could compromise my care and result in adverse complications.

HIPPA Patient Consent Form  |  EMAIL Privacy Acknowledgement

 
jornal-logos jornal-logos