Confidential Surgery Inquiry Form
Name
*
Phone Number
*
xxx-xxx-xxxx
Format: (000) 000-0000.
Email
*
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Date Picker Icon
Address
*
City State Zip Code
*
How did you hear about Dr. Chao?
*
Instagram
Google search
AI (ex: ChatGPT, Gemini, etc)
Referred by a friend (enter name below if known):
Other
What procedures are you interested in? Select all that apply
*
Rhinoplasty
Facelift / Neck Lift
Eyelid Surgery
Brow Lift
Lip Lift
Otoplasty
Chin Implant
Other
Height (ft' in")
*
Weight (lbs)
*
Are you in the process of losing weight?
*
Yes
No
Do you smoke?
*
Yes
No
Have you had facial / head & neck surgery before?
*
Yes
No
What previous treatments have you had on your face and/or neck? Select all that apply
*
Neurotoxins (ex: Botox / Dysport / Daxxify / etc)
Fillers (ex: Juvederm / Restylane / RHA / etc)
Laser Treatments
Threads / Ultherapy / RF Microneedling
Facials / Peels / Microneedling
Other
Do you have any of the following conditions? (Check all that apply)
*
Bleeding disorders
Heart conditions
Diabetes
Immune compromise
Other
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 hoping to have surgery?
*
ASAP
WIthin 3 months
3-6 months
Just researching
Other
Please upload 5 clear photos of your face and neck with the following guidelines: 1) Use a room with natural light and a plain background 2) Pull hair back in a ponytail or clip 3) Make sure the entire face and neck are visible
*
Browse Files
Drag and drop files here
Choose a file
Having another person take the photo from eye-level is optimal. Please include Front view. Left & Right Profile views. Left & Right Oblique views
Cancel
of
Submit
Should be Empty: