Alfred Sofer, MD, FACS
Diplomate of the American Board of Plastic & Reconstructive Surgery
Patient Evaluation Form
In order to serve you more expediently, we ask you to fill out this evaluation form. Dr. Sofer will review the information you provide a preliminary assessment and determine the best surgical option for you. You will receive a response from someone from our staff within 48 hrs (please check spam folder as well for a your response). Please note that this assessment is only preliminary and an in person consultation needs to be completed before the actual surgery.
Name
*
First Name
Last Name
Email
*
example@example.com
How Did You Hear About Us
*
Instagram
Facebook
TikTok
Google
Referral
Other
Phone Number
*
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age
Date of Birth
*
-
Month
-
Day
Year
Date
Height
*
Weight
*
Procedure of Interest (select all that apply)
*
Breast Augmentation (enlargement)
Breast Lift
Breast Reduction
Liposuction
Brazilian Butt lift (BBL, Fat transfer to the buttocks)
Abdominoplasty (tummy tuck)
Blepheroplasty (eyelid surgery)
Breast Implant Exchange
Face/Neck Lift
Other
Additional Information- Procedures of Interest
Past Medical History (please type NONE if no medical issues)
Past Surgical History and dates (please type NONE if not past surgeries)
Allergies (please type NONE if no Allergies)
Medications (please type NONE if you’re taking no medications)
Do You smoke?
*
Yes
No
Number of children (please type 0 if no children)
Age of Children
Frontal View image
*
Browse Files
Please upload a frontal view of the area You’d like to enhance. DO NOT INCLUDE YOUR FACE.
Cancel
of
Side view image 1
*
Browse Files
Please upload a right side view of the area You’d like to enhance. DO NOT INCLUDE YOUR FACE. ase upload
Cancel
of
Side view image 2
*
Browse Files
Please upload a left side view of the area You’d like to enhance. DO NOT INCLUDE YOUR FACE.
Cancel
of
Are you interested in the White Plains/Connecticut location?
CT
White Plains
Follow Us on Instagram @dralfredsofer
Submit
Should be Empty: