Cosmetic Surgery Patient Form
Tulsa & Oklahoma Surgical Arts
Patient Information
LOCATION
Tulsa Surgical Arts
Oklahoma Surgical Arts (Breast Only)
Consult Preference
In-Person
Virtual
Surgery Interested in?
Breast Augmentation
Breast Lift
Breast Aug/Lift
Tummy Tuck
Liposuction
Fat Grafting
Lower Face & Neck Lift
Chin Lipo
Submentoplasty
Brow Lift
Upper/Lower Blephs
Arm Lift
Rhinoplasty
Gynocomastia
Labiaplasty/Vaginoplasty
Otoplasty
Thigh Lift
BBL or Formal Butt Lift
Laser Skin Resurfacing
Other
Preferred Surgeon?
Dr. Angelo Cuzalina
Dr. Chase Nelson
Dr. Rola Eid
Dr. Carisa Champion
Dr. Sebastian Gutierrez
Dr. Tolomeo Pasquale
Unsure
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Race/Ethnicity
Marital Status
Occupation
Company Name
Emergency Contact Name
First Name
Last Name
Emergency Phone Number
-
Area Code
Phone Number
Medical Conditions/Questions
Are you currently taking any medications? If yes, please list them below and provide the purpose and dosage.
Do you have any allergies? If yes, please list them below:
Are you pregnant? (Women)
Yes
No
Do you drink alcohol?
Never
Occasionally
Daily
Do you drink coffee?
Never
Occasionally
Daily
Do you smoke?
Never
Occasionally
Daily
Are you taking any illicit drugs?
Never
Occasionally
Daily
Have you undergo any surgery before? If yes, please provide the surgery procedure's name, date, and reason.
Do you have a family history of any of the following? Please check the below, if none, then leave it blank.
Hypertension
Stroke
Heart Disease
Diabetes
Cancer
Anemia
Other
Medical History - Please select if you have a history of the following:
Yes
No
Asthma
Cancer
Chest pain
Chemotherapy
Diabetes
Heart Disease
Hepatitis
HIV
Kidney problems
Skin issues
Tuberculosis
Bleeding disorder
Psychiatric condition
Current Weight?
Maximum Weight (not while pregnant)?
Number of Children
Have you breastfed?
Yes
No
Have you ever had an abnormal mammogram?
Yes
No
Do you plan on becoming pregnant?
Yes
No
Do you currently have breast implants?
Yes
No
If you currently have breast implants, are they hard or painful?
Yes
No
Which type of consultation do you prefer?
Virtual
In-person
How did you hear about us?
Facebook
Twitter
Instagram
YouTube
Online Advertisement
Google Search
Referred by a friend
Newspaper/Magazine
Other
Please Upload 3 photos, in good lighting of your breast (without shirt and without bra) Front, left side, right side.
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