Personal Preference Form: Breast Enlargement 
Name:
Telephone:
Date of Appointment:
PART A: SURGICAL CONSIDERATIONS
1. Size. What cup size would you like to have?
2. What look do you wish for? Please choose from the following
1. Average for your build
2. Definitely larger than average
3. To have the ‘breast implant’ look
3. Type of Implant.
Do you have a preference for a particular type?
4. Location of the incision.
Do you have a specific preference?
5. Concerns
Do you have some particular concerns about breast implant surgery, maybe based on the experience of a friend, or some observations in magazines etc.?
   
PART B: OTHER CONSIDERATIONS REGARDING YOUR SURGERY
1. Is this your first experience of plastic surgery?
2. Have you wanted to have this surgery for a long time, or is it a recent desire?
3. Are you relaxed about the concept of plastic surgery?
4. Is there some event which has brought about your decision to have this surgery?
5. Are you hoping this procedure will change the way you dress, or your outward style or confidence?
6. Are you concerned about future breastfeeding?
7. Does the past publicity about silicone implants concern you? Would you like more information about today’s implants?
8. Are you having breast enlargement for yourself or partly to please another person?
Please attach two or more current photos of yourself, in profile and full face (.gif or .jpeg extension image files only):

Photo 1:
Photo 2:
Photo 3:
Photo 4:
 
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