Consultation Request form

CONSULTATION FORM
Name *

First nameLast 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*

MonthDayYear
Date
MEDICAL HISTORY
Please indicate your weight and height *
Do you have any of the following conditions?*

DiabetesHypertensionHypercholesterolemiaCardio-vascular diseaseSleep apneaBleeding disorderAnxiety or depressionAsthmaAnemiaNone of the above
Do you smoke?*

YesNo
How much alcohol do you drink?*

I don't drink alcohol at all1-2 alcoholic beverages a week2-5 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 augmentationBreast liftBreast reductionFat transfer to the breastsLiposuctionTummy tuck (abdominoplasty)Back/Buttock liftBrazilian Butt Lift (BBL)Arm/Thigh liftEyelid surgery/BlepharoplastyFace/Neck liftEar surgeryGynecomasty surgery (male breast surgery)None
WHAT NON SURGICAL PROCEDURE(S) ARE YOU INTERESTED IN?
INJECTABLES*

Facial fillersBotulinium toxin (Botox®/Dysport®/Xeomine®)Buttock augmentation with fillersPRP: Platelet-Rich Plasma for hair loss, facial rejuvenation, Vampire facialBotox for excessive sweatingNot interested
HAIR TREATMENTS*

PRP: Platelet-Rich Plasma for hair lossHair transplant (SmartGraft®)Hydrafacial® hair treatmentMicroneedlingNot interested
LASER TREATMENTS, FACIALS AND CHEMICAL PEELS OF THE FACE*

CO2 laser skin resurfacingDilated pores treatment with CO2 laserRosacea treatment with IPLDark spot treatment with IPLMicroneedlingChemical peel of the faceHydrafacial® treatmentNot 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?*

YesNo
If yes, which one?
Do you already have a consultation scheduled with us?*

YesNo
How did you hear of us?*

FacebookInstagramGoogleReferred by my doctorReferred by former patientOther
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 consultationNo preference: first availability for a medico-aesthetic consultation (injectables/laser, etc..)
What type of consultation would you prefer?*

Phone consultationVideoconference consultationIn person consultation
Pictures/Files. Please insert pictures if you are considering a virtual consultation or any file relevant to your consultation.

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.
Cancelof
Do you agree to transmit your information electronically to Forest Hill Plastic Surgery and its agents?*
Sign up for our newsletter to receive promotions and informations about our treatments*

YesNo
I certify that the information provided is accurate *
Should be Empty:

CONSULTATION FORM

MEDICAL HISTORY

WHAT SURGICAL PROCEDURE(S) ARE YOU INTERESTED IN?

WHAT NON SURGICAL PROCEDURE(S) ARE YOU INTERESTED IN?