Botox/dysport
Botox
Dysport
TMJ/ Masseter injection
Before and after photo
Testimonials
Fillers
Juvederm
Lip augmentation
Perlane
Radiesse
Restylane
Sculptra®
Testimonials
Eyelid/blepharoplasty
Lower EyeLid
Upper- EyeLid
FAQ
Liposuction
Liposuction
Frequently Asked Question
Smartlipo/laser lipo
Before and after photos
Testimonials
Tummy Tuck
Tummy Tuck
Tummy tuck v Lipo
Dermatology
Dermatology
Acne
Chemical Peel
Microdermabrasion
Dermabrasion
Weight Loss Surgery
Products
Spider vein removal
Face
Facelift/minlift
Brow lift
Eyelid lift
Testimonials
Butt Augumentation
Lasers
Laser hair removal
Laser spider vein removal
Laser Face Resurfacing
Testimonials
Breast
Gynecomastia/man boobs
Before and after photo
Testimonials
Locations
About us
Contact
Schedule or Cancel
an Appointment
FREE Online Consultation
*Required
Patient Online Consult Form:
Describe what you are trying to achieve areas, type of cosmetic procedure / surgery and any other questions or comments you have, e.g. I would like to do lipo, tummy tuck, eyelid surgery etc... at the end of this form, please attach pictures of the areas you would like us to assess.
Full Name:
First Name
Last Name
FULL ADDRESS
Street Address
City
State
Zipcode
CELL PHONE:
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EMAIL:
example@example.com
AGE
DOB:
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Month
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Day
Year
Date
EMPLOYER:
HOW LONG EMPLOYED THERE:
FAMILY DOCTOR NAME:
PERSON TO CONTACT IN CASE OF AN EMERGENCY:
Name:
First Name
Last Name
Relationship:
Phone:
Please enter a valid phone number.
REFERRED BY:
Newspaper:(name)
Magazine:(name)
Friend/Family:(name)
Other:
Medical History
Date of Last Blood Work (i.e. during physical, surgery, traveling, etc.) :
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Month
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Day
Year
Date
Do you have Kaiser Insurance?
Yes
No
Do you have any allergies ( penicillin, eggs, shellfish, metals, iodine, etc)?
Yes
No
If yes, please list:
Are you currently taking medications?
Yes
No
If yes, please list:
Do you have a bleeding disorder?
Yes
No
Do u have menstrual cycles that are heavy and last more than seven days?
Yes
No
Do you have a history of poor healing? (ie. Keloids, diabetes, etc)
Yes
No
Are you pregnant?
Yes
No
How many children do you have?
If you had children, did you have any through c-section?
Yes
No
Have you had a hysterectomy?
Yes
No
If Yes, Date?
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Month
-
Day
Year
Date
Have you had your gall bladder removed?
Yes
No
Have you had your appendix removed?
Yes
No
Have you had weight loss surgery?
Yes
No
Have you ever had Bell’s Palsy?
Yes
No
If yes,Which kind?
Do you smoke?
Yes
No
If yes, how often and how much:
Have you ever had any problems with general anesthesia?
Yes
No
Have you ever had any problems with local anesthesia?
Yes
No
Have you had any previous surgery?
Yes
No
If yes, please list with dates
Do you drink alcohol?
Yes
No
If yes, how often and how much:
Have you ever had a history of facial numbness or weakness?
Yes
No
Have you ever had a cold sore?
Yes
No
Have you ever had a herpes out-break?
Yes
No
If yes, how often?
Are you at risk for AIDS?
Yes
No
Have you ever had an AIDS test?
Yes
No
If yes, what was the result?
Do you have high blood pressure?
Yes
No
Do you have varicose veins?
Yes
No
Have you recently had a weight loss or gain (over 10 lbs)?
Yes
No
For surgical consults: current estimated weight (in lbs)
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Your height ( in feet )
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Have you ever had hepatitis or jaundice?
Yes
No
Do you have any eye problems?
Yes
No
If yes, please list:
Has any member of your family ever had a problem with local or general anesthesia?
Yes
No
Is there any medical condition that you have that I should know about?
Yes
No
If yes, please list:
Have you experienced a recent emotional crisis?
Yes
No
Explain: In the last two years, how many times have you been to emergency room?
You give us permission to talk to your doctor about your care at Vita Surgical Group.
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No
Upload 360(take pictures from different angles) images of the areas you want to be consulted on.
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Upload any recent labs within 12 months.
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