Consultation Patient Questionnaire - Houston, TX

Name(Required)

Date of Birth(Required)

Sex(Required)

Phone(Required)

Email(Required)

City & Time Zone(Required)

How were you referred to (or find) me?

Prioritize your concerns of the Face, Body and/or Breasts

Appearance Goals

(e.g. I want to wear a 2 piece swimsuit again or I want better proportion or I want to look the age I feel)

In your research, what have you seen that you like and do not like for each area you'd like Dr. Patronella to address?

Prior relevant surgery of the Face, Body or Breasts and/or cosmetic procedures with approximate year and any details that can be recalled.

(e.g. Breast augmentation with 350 cc smooth walled silicone implants under the muscle in 2008 and second Revision procedure with 450 cc silicone implants in 2012 for a size increase)

Number of Pregnancies and Births

Bra Size

Clothes Size

Height

Current Weight

Ideal Weight

Highest Ever Weight

Lifestyle

(active with exercise, sedentary, outdoor activities, sun exposure, etc)

Current or Past Medical History

(e.g. Hypertension or Diabetes)

Medications including hormones & supplements

Allergies

What type of consultation are you interested in?

Do you consent to using a *virtual platform for your consult?(Required)

*read more here.

Consent(Required)

I have read the privacy policy located on this website.

Consent(Required)

By completing this form, you are giving us permission to follow-up by phone, email or text.

Comments

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Consultation Questionnaire

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