ImplantInfo by Nicole - Complimentary Consultation Form
 

Patient:  Please bring this form to your doctor for your complimentary consultation.   This form may only be used for a plastic surgeon with the complimentary consultation logo.

Doctor: Thank you for supporting Nicole’s Website!

Please waive my consultation fee when I bring this form to my consultation at your office.

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My age: ____________

My height: _____ and weight _______

I have breastfed _____ children.

My ideal bra size would be: ___________

I have pictures to show you of my goals: __ yes ___ no

I have had cosmetic surgery before ___ yes ___ no

--What implant model, size, shape is best for me? 
--What incision approach do you recommend? 
--Should I have my implants over or under the muscle?
--Do I need a lift or other correction? 
--May I see pictures of your other patients’ results? 
--Do you have any patients I can contact to discuss their results?
--How long before I can work, exercise, etc? 
--Will I be able to breastfeed in the future?
--How will breast implants affect my breast cancer risk?
--Is your operating facility certified?
 

--What risks or complications should I be aware of?
--What is the total cost of the procedure?
--What financing arrangements are available to me?

--What are your policies for revision if I am not satisfied with my result?  What costs are involved, if any?
--What warranty coverage will I have with the implant model you recommend? 
--Will any of my choices (size, placement, incision, adding saline later) void the warranty?

Questions?  Can we make this form better?

To contact Nicole and ImplantInfo.com, please email nicole@implantinfo.com or fax 888-899-3114