Beverly Hills Cosmetic Surgery
Surgical Pre-Consultation Form
Name
*
First Name
Last Name
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
MEDICAL HISTORY
Current Weight
*
Lbs
Current Height
*
Do you have any of the following conditions?
*
Diabetes
Hypertension
Hypercholesterolemia
Cardio-vascular Disease
Sleep Apnea
Bleeding Disorder
Anxiety
Depression
Asthma
None
Other
Do you smoke?
*
Yes
No
Have you had any surgeries in the past? If so please list them below
Have you or any of your family members ever have an adverse reaction to an anaesthetic?
*
Please Select
Yes
No
Do you take any medication? If yes please list them all below. If no, write N/A
*
Do you have any drug allergies? (if yes please write the names of the drugs). If no, write N/A
*
What cosmetic surgery procedure(s) are you interested in ?
*
Have you ever had cosmetic surgery before?
*
Yes
No
What type of consultation would you prefer?
*
In -person Consultation
Telephone Consultation
Video Consultation
How did you hear about us?
Facebook
Instagram
Website
Ads
Cosmetic Lane
Friend/Family
Other
Pictures
Browse Files
Drag and drop files here
Choose a file
Thank you for providing good quality pictures. Front, 3/4 and lateral views of the area are required. Plain background is recommended and the picture should be taken at a distance of 2m from the subject.
Cancel
of
I certify that the information provided is accurate *
Do you agree to transmit your information electronically to Beverly Hills Cosmetic Surgery?
Please Select
Yes
We value your privacy. The Information/photos collected in this form will only be used for the purpose of your consultation with surgical team. Your pictures will not be shared with any third party. This form is HIPAA compliant.
Submit
Should be Empty: