SURGICAL ASSESSMENT FORM

Please complete this form as accuratley as possible. All fields marked with an * are mandatory and the surgeon will not be able to assess you for surgery without them completed.

PATIENT DETAILS

TITLE: FIRST NAME*: LAST NAME*: MIDDLE NAME:
GENDER*: DATE OF BIRTH*:

CONTACT INFORMATION

ADDRESS 1*: ADDRESS 2: STATE*: CITY*: COUNTRY*: POSTCODE*: EMAIL ADDRESS*:
TEL (MOBILE)*: TEL (HOME):

TRAVEL COMPANION DETAILS

NOTE: It is mandatory for all patients to travel with a carer. Clients who travel interstate without a carer are likely to be refused surgery or will need to pay for a private nurse to care for them during their stay.

I CONFIRM THAT I WILL BE TRAVELLING WITH A CARER :

CARER DETAILS:

TITLE: FIRST NAME: LAST NAME:

PRIVATE HEALTH INSURANCE (*if applicable)

HEALTH FUND: CLIENT NUMBER:
TEL (MOBILE): TEL (HOME):

PROCEDURES

REQUESTED PROCEDURE: 2ND REQUESTED PROCEDURE (IF ANY): 3RD REQUESTED PROCEDURE (IF ANY): PLEASE EXPLAIN YOUR DESIRES AND QUESTIONS IN FULL HERE. CUP SIZES, IMPLANT SIZES, INCISIONS, ANYTHING ON YOUR MIND AT ALL, PLEASE LET THE SURGEONS KNOW HERE:*

PATIENT MEDICAL CONDITIONS

HAVE YOU EVER BEEN TREATED FOR DEPRESSION REQUESTED PROCEDURE:
HAVE YOU BEEN DIAGNOSED WITH ANY PSCYCHIATRIC DISORDERS? REQUESTED PROCEDURE:

HABITS

SMOKING REQUESTED PROCEDURE:
DRINKING REQUESTED PROCEDURE:

WOMEN

IMPORTANT: It is mandatory that all females complete this section.

BIRTH CONTROL PILLS, HORMONE REPLACEMENT MEDICATIONS, HORMONE PATCH OR IMPLANT REQUESTED PROCEDURE:
HAVE YOU HAD ANY CHILDREN?: REQUESTED PROCEDURE:
ARE YOU PREGNANT NOW? REQUESTED PROCEDURE:
PLANNING FOR MORE PREGNANCIES? REQUESTED PROCEDURE:
AGE OF YOUNGEST CHILD: LAST BREASTFED ON (MONTH & YEAR):

IMAGES

In order to reach a decision on whether you may or may not be suitable to complete a procedure and to allow our plastic surgeons to make recommendation on the best plastic surgery procedure for you, we request that you provide photographs for the surgeon to evaluate. Please follow the examples below.

PLEASE NOTE: You will need to provide images for every procedure you have requested. For example if you are enquiry about breast Augmentation and Liposuction you will need to provide images for your Breasts and Body. Please insure that the images are clear and are taken by another party where possible as this will ensure that you will receive a more accurate assessment.

IMAGES BREAST

1

FORWARD FACING, ARMS AT SIDE

2

FORWARD FACING, ARMS ABOVE HEAD

3

RIGHT SIDE FACING, ARMS AT SIDE

4

LEFT HAND FACING, ARMS AT SIDE

IMAGES BODY

1

FORWARD FACING, ARMS AT SIDE

2

BACKWARD FACING, ARMS AT SIDE

3

RIGHT SIDE FACING

4

LEFT SIDE FACING

IMAGES FACE

1

FACE FORWARD LEVEL TO CAMERA

2

FACE FORWARD LOOKING UPWARDS

3

LEFT SIDE FACING

4

RIGHT SIDE FACING

5

FACE FORWARD LOOKING DOWNWARDS

TERMS & CONDITIONS