RHINOPLASTY

Name

First

Last

Email *

Phone

To complete your online assessment, please do send us your personal images as requested below;

1. Have you ever had surgery before? *

1/1. If yes, please provide further details *

2. Do you have any children? *

2/2. If yes, how many and when were they born? *

3. Are you a smoker? If yes, how many per day? *

4. Do you have nose fillers? *

4/4.When did you have it done?

5. Are you currently breastfeeding ? *

6. Is there any chance that you could be pregnant? *

7. Are you currently on any form of birth control? If yes, please specify and indicate whether it contains oestrogen. *

8. Are there any health concerns that we should be aware of? If yes, please specify. (for example, thyroids, hepatitis, tuberculosis, high/low blood pressure) *

9. Are there any hereditary health concerns that we should be aware of? If yes, please specify. (for example, hepatitis, heart disease, sickle cell anemia) *

10. Do you have any allergies? If yes, please specify. (for example, hay fever, latex etc.) *

11. Do you use or take illegal substances? If yes, please specify and indicate the last time you used. *

12. What is your current weight? *

13. What is your current height? *

14. How old are you? *

15. Do you have any upcoming surgeries or procedures [medical or not] that we should be made aware of? *

16. Are you currently taking any medication? *

17. If yes, what medication are you taking? *

18. Do you experience breathing difficulties? *

19. Have you had any previous nasal surgery? If yes, please state when and what type of procedure. *

20. When was this procedure carried out? [MM/YYYY] *

21. Have you ever experienced broken/fractures in your nose? If yes, when and how? *

22. What look would you like to achieve/what would you like altered? *

Notes

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