Evaluation Form

Fill out the following form so your surgeon can evaluate your procedure!

Whats your desired surgery date?

Date of Birth

Height (Ft)

Height (In)

Weight (lbs)

What procedure are you interested in?

Have you given birth in the last 6 months

Are you a smoker

Do you consume alcohol?

Are you currently taking any medication?

Do you have any medication allergies?

Have you had any of these surgical procedures in the past?

Have you Had a history of DVT or PE?

Do you have sickle cell trait?

Have you been diagnosed with any blood disorder?

Have you had an abortion or miscarriage in the last 3 months?

How did he find out about us?