| Name: |
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| Telephone: |
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| Date of Appointment: |
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Please bring some photographs of yourself, taken when you felt
happier with your appearance, to the pre-surgical consultation.
These will help in the surgical planning and assists us to
understand the look you wish to achieve.
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PART A: ABOUT YOUR APPEARANCE |
How do you currently feel
about your appearance?
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Which specific area
of the face do you think needs particular attention?
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Would you like that area returned to the way it looked in the past, or improved or changed in some way from the past?
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Are there other areas?
Please list in order of priority
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Have you recently received
any unsettling comments about your appearance?
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Who is your major concern
when it comes to your appearance? ie. self, partner
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What particular aspects
about having cosmetic surgery cause you concern, anxiety or
even frighten you?
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Were you happy with your
facial appearance when you were younger?
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| PART B: ABOUT YOURSELF |
Your spirituality - how do you rate yourself?
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How would you rate your sense of humour?
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Has some particular life event
triggered your decision eg a separation, divorce, death?
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Has a member of your family or a friend benefited from plastic surgery? If so, how did this influence your decision?
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Do you have the support of friends and family for your decision or are you doing this alone?
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Was this a difficult decision for you to
make, or was it an easy decision?
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Do you want to avoid having any alteration in appearance which could be noticed by others?
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Do you have any specific concerns you would like to raise?
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| Where do you want this surgery to lead your life in the future?
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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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