Client Questionnaire

Your Name (required)  

Mailing Address (required)

Work Phone  

Home Phone  

Your Email (required)  

Occupation  

Age (required)  

Marital Status: ---MarriedPartneredSingleDivorcedWidowWidower

Number of children under 18:  

Smoker? ---NoOccasionalModerateHeavyPipes/Cigars only

How did you hear about us? ---DoctorNewspaperWebTVAtlanta MagazineAtlantan MagazineFriendOther

Appointment Details

Should we contact you to setup an appointment? (required) YesNo

Should we leave a message if no one answers? (required) YesNo

What time of day is better for you? (required) ---MorningAfternoon

Consultation Level (required)
 Referrals Plus!
 The Patient Power Consult
 The Worry-Free Consult
 The Total Care Consult
 I'm not sure what I need and would like to talk about it.

Payment Method (required)
 MasterCard
 Visa
 American Express
 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?---Less than 6 months ago1 year ago2 years ago3 years ago5 or more years ago

If more than 5 years, please explain why a decision has not been made.

How many doctors have you consulted? 012345More than 5

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 and spouse? If so, what was the reaction?

Have you ever had cosmetic surgery before? ---YesNo

If "yes" to the above question, please describe the types of surgery you have had. Please indicate: type of procedure; who performed it; when and where it was performed.

Check this box to receive our informational packet:
 Yes, please send.

Other remarks:

Please enter the letters shown in the image below.