Los Angeles Facial Plastic Surgery Institute

Patient Name :
Mailing Address :
City :
State :
Zip Code :
Phone number :
Date of Birth :
Email address :

How did you hear about us?

What are the things you would like to change about your appearance?

For rhinoplasty patients: If your breathing is blocked, is it on one side or both? Does it change during the day?

Have you had any surgery to change your appearance? If so when and what was the purpose? How have things changed since the surgery?

What medical problems (if any) have you had?

What medications do you take?

Do you have any allergies to medicine?

Yes

If so, what medication(s)?

Do you have any problems with bleeding or excessive scarring?

Yes

Do you smoke cigarettes?

Yes

Photos:

Please take the six photos as shown below. Orient the face straight up and down and take them without a smile. For those with longer hair, tuck the hair behind the ears so that the ears can be seen from the front and side views.

Figure 1

Figure 2

Figure 3

Figure 4

Figure 5

Figure 6

The photos can be taken at a studio for the best outcome. However, if taking the photos at home with a point-and-shoot digital camera, zoom all the way in and step back until the face is framed as shown in the above examples. Be sure they are in focus with good lighting against a solid colored background.
Our office will contact you via email with the results of your consultation.

Phone: (310) 785-9325

Fax: (310) 201-9665

2080 Century Park East Suite 1700 Los Angeles, CA 90067