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Otoplasty Self-Evaluation Tool
To better understand your options, we offer this 1-minute self-evaluation.
16
Questions
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1
What is your age?
*
This field is required.
Under 18
19–40
41–60
61+
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2
How do you rate your overall health?
*
This field is required.
Good
Fair
Poor
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3
Do you smoke, vape, or use nicotine products?
*
This field is required.
YES
NO
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4
What is your height?
*
This field is required.
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5
What is your weight?
*
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6
Do you take prescription medications?
*
This field is required.
YES
NO
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7
What are your main ear concern(s)?
Lobe Size
Protrusion from side of head
Torn ear lobe or "gauge" closure
Other
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8
Have you had any previous ear surgery?
YES
NO
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9
Which photo most resembles you?
*
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10
Any additional comments or questions?
*
This field is required.
YES
NO
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11
Please provide your additional comments or questions.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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12
Please enter your full name
*
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First Name
Last Name
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13
Your Date of Birth
*
This field is required.
-
Date
Month
Day
Year
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14
Select your preferred method of contact
*
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Text
Phone
E-mail
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15
Please enter your phone number
*
This field is required.
Area Code
Phone Number
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16
Please enter your e-mail address
*
This field is required.
example@example.com
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