SSI - Consultation Form

You will find below a one page form that will take you through the plastic surgery consultation process. Click on the procedures that interest you and a list of itemized procedures will appear along with an area for you to attach digital photos. We also need you to fill out the medical history form for the surgeon to review. In order for you to have the most accurate consultation from SSI we ask you to please take your time and provide as much information as possible as to your desires, goals, expectations and medical history. Once the surgeon has reviewed everything, we will then request a best time to call you and discuss the surgeons recommedations and approved procedures so that any questions can be immediately discussed and a surgery plan can be approved. You will then receive a quote based on your consultation. Please let us know if you have any questions and thank you for choosing SSI to help you with your plastic surgery journey.

Before filling out the Consultation Form, please make sure that you have:

	Digital Pictures to add
	Consultation cannot be completed without pictures
	Measuring Tape

Full Name:

(First, Last)

E-mail:

Please mark which procedure(s) you are interested in.
Facelift	Mini Facelift	Contour Threads
Brow Lift	Forehead Lift	Eyelid Surgery
Rhinoplasty	Rhinoseptoplasty	Wrinkle Treatment
Dermabrasion	Micro Dermabrasion	Chemical Peel
Lip Enhancement	Ear Surgery	Chin Enhancement
Cheek Enhancement	Hair Transplantation	Surgeon's Recomendation

Please attach your photos below for the sugeons review. It is very important the surgeon has clear photos of the areas in order to give you an accurate consultation. Please review the sample pictures so you know what views we need. Max. File Size: 1 MB Per Picture
Picture 1:		A Front View
Picture 2:		A Side View (right side)
Picture 3:		A Side View (left side)
Picture 4:		Addtional Picture (if needed)
Picture 5:		Additional Picture (if needed)

Compression Garments: We will need some measurements to provide you with the right garments after your surgery. *(For Chin Enhancement and Facelift procedures only)
Diameter Of Your Neck (inches):

Please mark which procedure you are interested in.
Breast Augmentation	Breast Reduction
Breast Lift	Breast Reconstruction
Breast Lift with Augmentation	Surgeon's Recomendation

Breast Measurements
In order for your surgeon to determine the correct size implant he will need the following measurements.
1- Armpits 360 •

2- Nipples 360 •

3- Ribcage 360 •

4- Waist 360 •

5- Hips 360 •

6- V Section to Nipples:
The "V" is the notch in your breastplate, between your collarbones and approximately 3 inches below your adams apple.
6.1- V Section to Right Nipple:

6.2- V Section to Left Nipple:

Please measure from the middle of each nipple to your mammory fold. (the crease where your breast meet your chest)
7-Nipples to Bottom of Breast:

8-Cup Size
What cup size are you now:	What cup size you would like to be:

9- Mammography
Have you had a mammography? If yes, when?

Please attach your photos below for the sugeons review. It is very important the surgeon has clear photos of the areas in order to give you an accurate consultation. Please review the sample pictures so you know what views we need. File Size: 1 MB Per Picture
Picture 1:		A front view with arms at side
Picture 2:		Right side view with arms at side
Picture 3:		Left side view with arms at side
Picture 4:		Additional Picture (if needed)
Picture 5:		Additional Picture (if needed)

Please mark which procedure(s) you are interested in.
Tummy Tuck	Liposuction Abdomen	Liposuction Arms
Mini Tummy Tuck	Liposuction Hips	Liposuction Chin
Buttock Aug/Fat Grafting	Liposuction Thighs	Liposuction Other
Buttock Aug/Implants	Liposuction Buttock	Surgeon's Recomendation

Optional- To help us better understand what your goals are we have listed common desires.

Reasons why you want a Tummy Tuck Procedure...

Reasons why you want a Liposuction Procedure..

Reasons why you want a Buttock Enhancement Procedure...

Excess skin
Stretch marks
Muscle repair
Other:

I work out but this area won't go away
I would like this area to be more in proportion to the rest of my shape
I would like to have better curves
I am looking to lose as many inches as possible
Other:

I want a "bubble butt"
My main concern is the lower part of my buttocks
I want the shape changed
I like my shape I just want more projection
Other:

Please attach your photos below for the sugeons review. It is very important the surgeon has clear photos of the areas in order to give you an accurate consultation. Please review the sample pictures so you know what views we need. you can wear undergarments however please make sure they are not tight or cover the areas we need to review. File Size: 1 MB Per Picture
Picture 1:		A Frontal View (knees to shoulders)
Picture 2:		A Right Side View (knees to shoulders)
Picture 3:		A Left Side View (knees to shoulders)
Picture 4:		A Back View (knees to shoulders)
Picture 5:		Additional photo

Number of children you have?

Have you had a C section?

Yes

No

Do you plan on having more children?

Yes

No

Has your weight been stable for 6 months or more?

Yes

No

Compression Garments: We will need some measurements to provide you with the right garments after your surgery.
Diameter of your waist (inches):

Diameter of your hips (inches):

Diameter underneath your thighs (inches):

What are your goals and expectations of the procedures you are requesting?

How long have you been considering plastic surgery?

Have you had plastic surgery in the past? If so which procedures have you had and were you happy with the results?

Do you have any questions about the procedure(s)?

Medical History.
Patient Information
Home phone: *
Work phone:
City of Residence: *
Preferred contact:	E-mail Phone
Birthdate (mm/dd/yyyy): *	/ /
Sex: *	Male Female
Height : *
Weight: *

Medical History
List any medications you take including herbal medications :
List all major illnesses or injuries (diabetes, high blood pressure, emphysema, heart attacks, etc):
Do you have any allergies to medications? *	Yes No
If yes, please list the medications:
List all eye illnesses or injuries (crossed/lazy eye, cataract, glaucoma, macular degeneration, abrasions, etc.):

Social History
Do you smoke? *	Yes No
If so, how much?	packs / day
Do you drink alcohol? *	Yes No
If so, how much?	drinks / day
Do you exercise?	Yes No
If so, how often?	days / week

Do you currently have any problems in the following areas?
	Yes	No	If yes, please explain:
General / Constitutional (fever, weight loss, other)
Ears, Nose, and Throat (cold, sinus, chronic cough)
Cardiovascular (heart, vessels, etc.)
Respiratory (asthma, emphysema, etc.)
Gastrointestinal (ulcers, intestinal disease, etc.)
Genital, Kidney, Bladder
Skin (rosacea, skin cancer, psoriasis, etc.)
Neurological (MS, stroke, seizures, etc.)
Psychiatric (anxiety, depression, etc.)
Endocrine (diabetes, thyroid, etc.)
Blood / Lymph (bleeding disorder, high cholesterol, anemia, etc.)
Allergic / Immunologic (lupus, hay fever, rheumatoid arthritis, etc.)