Evaluation Form

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

Date of Birth

Height (Ft)

Height (In)

Weight (lbs)

What procedure are you interested in?

Do you consume alcohol or nicotine, if so how often?

If you have had any surgical procedures in the past, please mention their name and date.

If you are on any medication please mention it.

If you have any genetic disorder mention it below:

If you have any drug or other allergies mention them below:

If you have had any Natural births, Abortions or C-section in the past mention them here and include the dates :

Any history of Deep vein thrombosis?

Any history of Pulmonary Embolism?

Do you have diabetes, thyroid problems (hypothyroidism or hyperthyroidism)?

Do you have Multiple Sclerosis (MS)?

Do you have Epilepsy?

Do you have Glaucoma?

Are you vaccinated for COVID-19?

Have you had COVID-19? before?

If you have any other relevant medical conditions mention them here: