Surgical Consult Pre-Assessment
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about Dr. Bayrak?
*
Have you consulted with Dr. Bayrak previously?
*
Yes
No
What procedures are you interested in? Select all that apply.
*
Face and neck lift
Brow lift
Upper eyelid blepharoplasty
Lower eyelid blepharoplasty
Facial fat transfer
CO2 laser resurfacing
Rhinoplasty
Lip lift
Chin implant
Buccal fat removal
Have you consulted with other surgeons about these procedures?
*
Yes
No
Height (ft, in)
*
Height (ft, in)
*
Weight (lb)
*
Are you in the process of losing weight?
*
Yes
No
Are you losing weight with the help of GLP-1 or GLP-1/GLP-2 injectable medications (e.g. Wegovy, Ozempic, Mounjaro, or semaglutide)?
Yes
No
How many pounds are you from your goal weight?
Do you smoke?
*
Yes
No
What previous treatments have you had on your face and/or neck? Select all that apply.
*
Neuromodulators (e.g. Botox, Dysport, etc)
Hyaluronic acid fillers (e.g. Juvederm, Restylane, etc)
Sculptra
Radiesse
Ultherapy
Thermage
Resurfacing lasers (e.g. Fraxel, Halo, Moxi, etc)
Threadlift procedures
Radiofrequency (RF) microneedling (e.g. Morpheus 8, Potenza, etc)
None of these
Do you have any of the following medical conditions?
*
Cardiac (heart) issues (e.g. coronary artery disease, valve disorders, etc)
Pulmonary (lung) issues (e.g. asthma)
Blood dyscrasias (e.g. anemia, hemophilia, von Willebrand disease)
Hypertension/high blood pressure
Connective tissue disorders (e.g. Ehlers-Danlos syndrome, Marfan syndrome, etc)
Collagen vascular diseases (e.g. lupus, rheumatoid arthritis, etc)
History of DVTs, pulmonary embolism, or other excessive blood clotting
NONE OF THE ABOVE
Please list any current medications. If you have none, type "none."
*
Please list any allergies (including antibiotics and anesthetic agents). If you have none, type "none."
*
When are you interested in having surgery?
*
Every procedure aims for natural improvement, not perfection. What percentage of improvement would you feel happy with?
*
Subtle (20% to 40%)
Moderate (40% to 60%)
Significant (60% to 80%)
Dramatic (80% to 100%)
Have you had any facial cosmetic surgery in the past?
*
Yes
No
What facial cosmetic surgeries have you had done? Please include the procedure and the date.
Did you experience any complications from your previous facial cosmetic surgeries?
Yes
No
Please explain any and all complications below.
Are you pleased with the results of your previous facial cosmetic surgeries?
Yes
No
Please explain why not.
In order to complete your pre-assessment, please upload photos of your face and neck as shown below for assessment by Dr. Bayrak. Please find a room with abundant natural light with a solid-colored background, and pull your hair back in a ponytail. For optimal photos, please have another person photograph you from a few feet away. The lens of the camera should be at eye level and your chin should be parallel with the floor. Please ensure that your entire face and neck are within the frame of the picture.
*
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