Online Consult

Consultation Intake Form

Thank you for choosing Dr. Giancarlo McEvenue Plastic Surgery!
Name*

First NameLast Name
Email*

Confirmation Emailexample@example.com
Phone Number*
Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date
Zip Code/Postal Code*
Medical History
Current Weight*
Lbs.
Height (in ft)*
Feet
( inches)*
Inches
Please describe what you are looking for. This may include specific areas, body goals or things you want to enhance. The more information you provide to us the better.*
Have you ever had surgery before?*

YesNo
Please provide details on previous surgical procedures*
Do you take any medications?*

YesNo
Please list all medications you take*
Include any herbal medicine, supplements, diet pills, etc.
Do you have any medication allergies?*

YesNo
Please list your allergies*
Include any herbal medicine, supplements, diet pills, etc.
Do you have any medical conditions?*

YesNo
Check all medical conditions that you have*

AnemiaAsthmaCancerCardiac diseaseDiabetesHypertensionPsychiatric disorderEpilepsyHistory of Blood ClotsMalignant HyperthermiaHIVOther
Please Explain what other medical condition you have*
Did you ever smoke nicotine cigarettes or vape?*

Yes I currently smokeI Quit smokingNever smokedOther
Please Provide more information on how long you smoked for and when you quit?*
Have you or someone in your family ever had a Bloodclot?*

YesNo
Please provide more information on who/why/when of the bloodclot.*
How Did you hear about us?*

Previous PatientTik TokInstagramFacebookGoogleRealself
Please upload your photos*

Please include area you want to be evaluated: FRONT | LEFT SIDE | RIGHT SIDE| BACK. (Good lighting, no filters, face is not necessary to include for body procedures).
Cancelof
Do you agree to transmit your information electronically to Dr. Giancarlo McEvenue?*
Dr.Giancarlo takes privacy very seriously and complies with HIPAA policies whenever possible. However many of the communications used today (emails, text, phone, web, social media, etc.) are not HIPAA compliant. By selecting "I Agree" I acknowledge, understand and accept that using these forms of communication it might not be fully compliant with all HIPAA regulations.
Do you agree to be contacted via SMS text message regarding your consultation request?
We will never share, trade, or otherwise sell your personal information such as Phone numbers and SMS consent to third parties under any circumstances.
Should be Empty:

Consultation Intake Form

Medical History