Patient Evaluation Form

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 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
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
Hight *
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) Facelift
Past Medical History (please type NONE if no medical issues)
Past Surgical History (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)
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 Miami or Connecticut location? (Tummy tuck is not offered in CT at this time)

CT (near NYC) Miami
Would you be interested in the CT location for a more personalized experience?

Yes No
Should be Empty:

Alfred Sofer, MD, FACS

Patient Evaluation Form