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COSMETIC SURGERY ONLINE CONSULTATION

Attention! All fields marked by an asterix (*) are mandatory

TITLEFIRST NAME *
Mr Ms Mrs Miss Dr  

SURNAME *

DATE OF BIRTH dd/mm/yyyy *

OCCUPATION *

MARITAL STATUS *
Single Married Divorced Widowed

NUMBER OF CHILDREN *
0 1 2 3 4 5 6+

HOME PHONE *

WORK PHONE

MOBILE *

WHAT IS THE BEST TIME FOR US TO CALL YOU? *

EMAIL *

MAILING ADDRESS

ADDRESS *

SUBURB *

STATE *
QLD NSW VIC SA WA ACT NT Tas Other

POSTCODE *

MEDICAL HISTORY

HAVE YOU HAD ANY SERIOUS ILLNESS REQUIRING HOSPITALISATION
Please explain: *

WHAT MEDICATIONS ARE YOU TAKING, THIS INCLUDES CONTRACEPTIVE PILL? *

WHAT VITAMINS, HERBALS SUPPLEMENTS DO YOU TAKE? *

AVERAGE ALCOHOL CONSUMPTION
Standard drinks per week
Select 1-2 2-5 5-8 8-15 15-20 20+

HAVE YOU SUFFERED FROM POOR HEALING *
YES NO

ARE YOU PREGNANT? *
YES NO

DO YOU SMOKE? *
YES NO

IF SO, HOW MANY?

Do you suffer from?

All emails are treated as strictly confidential.

COSMETIC SURGERY ENQUIRY *

This gives you the opportunity to discuss why your coming to see Dr Colagrande and how you are feeling, for example:

“I am unhappy with my breasts shape and size” or “I have dieted and exercised but I can’t get rid of the fat on my hips and feel out of proportion.”

We would like your permission to contact your General Practitioner as necessary.

I GIVE PERMISSION TO CONTACT MY GP *
YES NO

GP NAME

GP ADDRESS

GP PHONE NUMBER

SURGICAL HISTORY

IF SO PLEASE LIST OPERATIONS AND YEAR.
Operation performed / Year of Operation / Comment

DID YOU HAVE ANY PROBLEMS WITH THE ANAESTHETIC?
Please explain:

ARE YOU ALLERGIC TO ANY MEDICATIONS, PLEASE LIST MEDICATION AND WHAT HAPPENED?
e.g penicillin caused my throat to swell up.

HOW LONG HAVE YOU BEEN CONSIDERING COSMETIC SURGERY?

HAVE YOU EVER HAD ANY SURGERY PREVIOUSLY, COSMETIC OR NON COSMETIC. *
YES NO

If you are considering breast enlargement
What body and bra size are you?
For example, size 8A or 12B?

If considering face-lift surgery
Have you tried anti-wrinkle injections or fillers?
YES NO

If considering Liposuction
Have you tried to diet & exercise but have trouble loosing stubborn fat?
YES NO

PHOTOS

This completes the necessary medical details to allow Dr. Colagrande to ensure that it is safe to consider a procedure. The next section gives additional details required to assess breast enlargement and liposculpture patients.

Photos will greatly assist Dr Colagrande in assessing your surgical needs.

Digital photographs may be attached to this form using the attachment tool below.

1ST IMAGE FILE.

2ND IMAGE FILE.

3RD IMAGE FILE.

If you are experiencing trouble sending photos with this tool please pleased try contact us at: 1800 007 008

FEEDBACK

We value your feedback and comments. In order for us to improve our services could you please complete the information below. *

How did you hear about us? *

Do you have any suggestions that you feel could improve our services? *

SUBMIT YOUR INFORMATION

This online consultation does not take the place of a formal consultation with Dr. Colagrande, during which a complete assessment of your needs and an in depth discussion of the procedure and possible risks will be undertaken.

DISCLAMER: I confirm that the above health history is accurate and complete. I understand that withholding any medical information will be detrimental to my health and safety.

Please type in your email address to confirm the above information is accurate and complete: *