Nasal Forms

Nasal History
Name*

First NameLast Name
Email*
example@example.com
Phone Number (Include country code for international)*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
City, State, Country*
Have you ever had nasal surgery or filler in the nose? IF so, what was performed/placed and when? Please include dates and any materials used (ears, ribs, donor ribs, synthetic materials, etc)*
Have you ever had nasal trauma? If so, what occurred and when?*
Are you currently using any nasal sprays (Afrin, Flonase, etc)? If so, how often *
Do you have a diagnosis, or suspicion of Obstructive Sleep Apnea? If so, are you wearing any type of mask to sleep?*
Do you have any other significant medical conditions (autoimmune, organ disfunction, blood thinners, pulmonary, cardiac, etc)?*
Do you wear glasses, contacts, both, or neither? *
Do you breathe better from one side or the other? If so, which one is better and which is worse?*
Do you currently smoke? Do you use any nicotine products (Zyn, patches, vaping, etc)? *
How did you discover our practice (Google, Reddit, Instagram, referral, etc)?
Are you interested in an in-person or virtual (Zoom) consultation?

Picture Uploading
In order to improve the quality of the consult, please upload the 7 requested photos of the nose using your phone or a similar high-quality camera. Ideally the images will be in good light and with a solid background. This works best if you have someone else take the photos for you using the rear camera.
Upload image of Front View*

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Upload image of Base View*

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Upload image of Head Down View*

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Upload image of Right Oblique View*

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Upload image of Right Profile View*

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Upload image of Left Oblique View*

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Upload image of Left Profile View*

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Should be Empty:

Introduction