The Informed Choice: Cosmetic Surgery Consulting

Appointment Survey

Client Questionnaire
First Name (required):
Last Name (required):
Address (required):
City:
State:
Zip Code:
Phone Number:
E-mail (required):
Occupation:
Age:
Marital Status:
Number of children under 18:
Smoker?
How did you hear about us? (required)
Appointment Details
Should we contact you to setup an appointment? (required)
Should we leave a message if no one answers? (required)
What time of day is better for you? (required)
Consultation Level (required)  Referrals Plus!
 The Patient Power Consult
 Non-surgical Options Consult
 The Total Care Consult
 I'm not sure what I need and would like to talk about it.
Payment Method (required)  MasterCard
 Visa
 Cashier's Check/Money Order
 Personal Check (needs to clear prior to consultation, for phone consults only)
Specific Information about Your Surgical Needs and Experience
What specifically would you like to improve?
When did you first consider surgical correction?
If more than 5 years, please explain why you have waited.
How many doctors have you consulted?
Which doctors have you consulted and when? Please list each on a separate line.
What was the outcome of the consultations?
If you have consulted more than five doctors and have not reached a decision, why not?
Have you discussed the possibility of surgery with your family/spouse? If so, what was the reaction?
Have you ever had cosmetic surgery before?
If “yes” to the above question, please describe the types of surgery you have had. Please indicate type of procedure, who performed it, and when and where it was performed.
Other remarks: