CONSULTATION FORM
Name
*
First name
Last name
Email
*
Do you agree to receive periodic emails, promotions or newsletters?
Yes
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of birth
*
-
Month
-
Day
Year
Date
MEDICAL HISTORY
Please indicate your weight and height
*
Do you have any of the following conditions?
*
Diabetes
Hypertension
Hypercholesterolemia
Cardio-vascular disease
Sleep apnea
Bleeding disorder
Anxiety or depression
Asthma
Anemia
None of the above
Do you smoke?
*
Yes
No
How much alcohol do you drink?
*
I don't drink alcohol at all
1-2 alcoholic beverages a week
2-5 alcoholic beverages a week
>5 alcoholic beverages a week
Do you take any medication?
*
Do you have any drug allergies? (if yes please write the names of the drugs)
*
WHAT SURGICAL PROCEDURE(S) ARE YOU INTERESTED IN?
Select the procedure(s) you are interested in
*
Breast augmentation
Breast lift
Breast reduction
Fat transfer to the breasts
Liposuction
Tummy tuck (abdominoplasty)
Back/Buttock lift
Brazilian Butt Lift (BBL)
Arm/Thigh lift
Eyelid surgery/Blepharoplasty
Face/Neck lift
Ear surgery
Gynecomasty surgery (male breast surgery)
None
WHAT NON SURGICAL PROCEDURE(S) ARE YOU INTERESTED IN?
INJECTABLES
*
Facial fillers
Botulinium toxin (Botox®/Dysport®/Xeomine®)
Buttock augmentation with fillers
PRP: Platelet-Rich Plasma for hair loss, facial rejuvenation, Vampire facial
Botox for excessive sweating
Not interested
HAIR TREATMENTS
*
PRP: Platelet-Rich Plasma for hair loss
Hair transplant (SmartGraft®)
Hydrafacial® hair treatment
Microneedling
Not interested
LASER TREATMENTS, FACIALS AND CHEMICAL PEELS OF THE FACE
*
CO2 laser skin resurfacing
Dilated pores treatment with CO2 laser
Rosacea treatment with IPL
Dark spot treatment with IPL
Microneedling
Chemical peel of the face
Hydrafacial® treatment
Not interested
OTHERS
*
Medically supervised weight loss program (with or without medication)
Vitamin therapy
"Fat melting" with Coolsculpting®
Minor procedures: moles, cysts and lipoma (non OHIP)
Not interested
Concerns or special demands
Have you ever had a cosmetic surgery/medicine treatment before?
*
Yes
No
If yes, which one?
Do you already have a consultation scheduled with us?
*
Yes
No
How did you hear of us?
*
Facebook
Instagram
Google
Referred by my doctor
Referred by former patient
Other
Which professional would you like to consult with
*
Dr David Boudana (Board-certified Plastic Surgeon)
Dr Haley Augustine (Board-certified Plastic Surgeon)
Dr Ronald Levine (Board-certified Plastic Surgeon)
Dr Ogi Solaja (Board-certified Plastic Surgeon)
“Fast track consultation for Dr Boudana” (consultation with our nurse first to fast track your consultation and decrease wait time with Dr Boudana)
Nurse Sasha (facial aesthetic injections, laser and biostimulators)
Nurse Haley (facial aesthetic injectables)
No preference: first availability for a plastic surgery consultation
No preference: first availability for a medico-aesthetic consultation (injectables/laser, etc..)
What type of consultation would you prefer?
*
Phone consultation
Videoconference consultation
In person consultation
Pictures/Files. Please insert pictures if you are considering a virtual consultation or any file relevant to your consultation.
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FOR VIRTUAL CONSULTATIONS: Thank you for providing good quality pictures of the area: front view, 3/4 and lateral views. Plain background is recommended and the picture should be taken at a distance of 2m from the subject.
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