PERSONAL INFORMATION
Full Name
Surname
Date of Birth
Gender
Male
Female
Prefer not to say
Language
Country
Country
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d’Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor-Leste)
Ecuador
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Eswatini
Ethiopia
Fiji
Finland
France
Gabon
The Gambia
Georgia
Germany
Ghana
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Guatemala
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Indonesia
Iran
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Ireland
Israel
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Jamaica
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Korea, North
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Kosovo
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Libya
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Madagascar
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Malaysia
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Mali
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Micronesia, Federated States of
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
New Zealand
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Niger
Nigeria
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Norway
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Pakistan
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Panama
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Paraguay
Peru
Philippines
Poland
Portugal
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Romania
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Saint Kitts and Nevis
Saint Lucia
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Samoa
San Marino
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Senegal
Serbia
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Slovakia
Slovenia
Solomon Islands
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Sudan
Sudan, South
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Sweden
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Tonga
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Uzbekistan
Vanuatu
Vatican City
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Vietnam
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Zimbabwe
Email Address
Phone Number
How did you hear about us?
MEDICAL INFORMATION
Do you have nasal breathing problems?
Is your breathing problem primarily on one side or both?
Where would you like to have your surgery?
When does it bother you most? (season, time of day, with exercise, etc.)
Allergies: Are you allergic to or have you ever had a reaction to any medication, drug or local anesthetic? Please list:
Medications: Are you now or have you ever taken any medications on a regular basis? (aspirin, birth control pills, vitamins included)? Please list:
Are you now or have you ever taken a prescription or over the counter medication for allergies, stuffiness, difficulty breathing, sinuses or other nasal problems? Please list:
Have you had any previous nasal surgery? * Please answer(n/a) if not applicable *
If yes, how many?
Was it to improve breathing , the appearance, or both?
When was your last surgery performed?
Who did your surgeries? (name of doctor and specialty)
Do you know if any cartilage from inside your nose (the nasal septum) has been removed to correct a deviated septum or used as a graft to improve the shape of your nose?
Has any cartilage or bone from other parts of your body (ribs, ears, skull, etc.) or any implants (artificial grafts) been used in your nose (Be specific)?
TAKE 6 PHOTOGRAPHS
For me to be able to assess your nose and face I will also require photo’s. They must be taken in good lighting with a solid-colored background with no shadows on the face. You may take them at home using a camera with a zoom lens. You may also have pictures taken at a studio. Six (6) are required: One from in front, two (2) from each side, two (2) from a three-quarter view and one from below. Please see the example below. Once done, highlight all the photos, right-click and select either compress, zip or archive. Once done you should have an additional file ending in .zip, .rar or .7z. Upload this file.
Upload Photos
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