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Submit to eConsultation

The information we ask below is important to determine the best possible cosmetic surgery options for you. It is to ensure that the cosmetic surgeon you select have some essential information about you to provide you with an appropriate assessment.

Your identity and information will be kept strictly confidential, and we will not reveal this information for any purpose other than for medical and cosmetic surgery assessment.

• Step 1: Add your personal & contact information.
• Step 2: Select your procedure(s) of interest.
• Step 3: Rate your desired plastic surgery changes.
• Step 4: Add your physical & medical background information.
• Step 5: Upload your photo, and add your surgical timeline.

___________________________________________________________________________________

Step 1: GENERAL BACKGROUND

(required fields in bold)

Title:

Ms Miss Mr Mrs

First Name:

Middle Name:

Last Name:

Telephone:

Username:

Email:

Height:

 cm

Weight:

 kg

How often do you exercise?

Age Group:

Below 18 18-30 30-40 40-50 50-60 60-70 70 Above

Please describe your reason, motivation & desire for seeking cosmetic surgery.

How do you expect to see yourself, your looks, or your lifestyle change after the surgery?

Step 2: PROCEDURES OF INTEREST

Please indicate the areas or procedures in which you are interested. Leave blank if you are not sure.

Facial contour, skin and its condition

Spot reduction Pore reduction Laser to tighten skin Fat transfer or derma filler Stem cells /fat grating facelift Full facelift Mini facelift Contour Thread lift Silhouette thread lift Endotine bio-absorbable thread lift Other thread lift

Top areas such as forehead, brow, eyes

Brow lift Forehead lift Lower eyelid surgery Upper eyelid surgery

Mid areas such as nose, frown and smile area, cheek

Rhinoplasty Mid facelift Reshaping of cheek Cheek implant

Lower areas such as chin, jowl, neck

Chin Implant/augmentation Double Chin reduction/Chin liposuction Reshaping of jowl Neck lift Neck liposuction

Step 3: DESIRED CHANGES

Please indicate the extent to which you agree or disagree with the following statements: Scale from 1 (strongly disagree) to 7 (strongly agree)

I look tired and older than I should be:

1 2 3 4 5 6 7

My facial skin is wrinkled, saggy, or lumpy:

1 2 3 4 5 6 7

I have poor/dull complexion with sun damage/aged spots:

1 2 3 4 5 6 7

I feel miserable, unhappy, or ugly and want to improve:

1 2 3 4 5 6 7

I have bags under my eyes or droopy eyelids:

1 2 3 4 5 6 7

I want to straight my nose bridge:

1 2 3 4 5 6 7

I have deep lines and furrows near the corner of my mouth:

1 2 3 4 5 6 7

My cheeks are hanging and pushing down:

1 2 3 4 5 6 7

I'm jowly and want narrower, more defined jaw line:

1 2 3 4 5 6 7

My neck is wrinkled, saggy or has loose hanging skin:

1 2 3 4 5 6 7

I have a double chin or hanging fatty skin under chin:

1 2 3 4 5 6 7

Step 4: PHYSICAL & MEDICAL BACKGOUND

Do you smoke?

Yes      No

How many cigarettes each day?

Do you drink alcoholic beverages daily?

Yes      No

Have you had any cosmetic surgical operations in the past?

Yes      No

What was the procedure?

Did you have any unusual reactions to anaesthetics during the surgical operations?

Yes      No

What were the unusual reactions?

Are you allergic to any medications?

Yes      No

List of medications allergic to?

Do you suffer from any of the following?

High blood pressure
Chest pains/infection
Diabetics
Asthma
Hepatitis
Rheumatoid arthritis
Blood clots
Excessive bleeding
Cold scores

Any medical history that your surgeon should know:

Step 5: SURGEONS AND SURGICAL TIMELINE

Do you have any particular surgeons in mind for the surgery?

Yes      No

List your surgeon names and locations

No, I'm willing to:

Travel to see top notch surgeons anywhere in the world

Prefer to see surgeons in my areas

Both

Do you have any particular timeline for the surgery?

From:    To: 

Upload your photos from different angles.

Photo 1:

Photo 2:

Photo 3:

Photo 4:

CAPTCHA Code:

Enter CAPTCHA Code:

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Interested in learning about what's NEW in facial surgery? Check here:

Stem cell Facelift: Fat (stem cells) Injection.

Silhouette lift : a close cousin of ENDOTINE, the Madonna ribbon threadlift

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Short Scar, Mid facelift

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