The surgeon will require photos as well as your completed form to provide you with feedback. Photos should be sent to private@stunningmakeovers.com Please see below for further details.

*Full Name:

*Age:

*Gender:

*Date Of Birth:

*Height (cm):

*Weight (kg):

*Email:

*Phone:

*Postal / Street Address:

*Suburb:

*City:

*Region / State:

*Postcode / ZIP:

*Country:

*Planned Date of Surgery:

*Flying home on (Date):

*What procedures do you require?:

*What results do you expect?: (Please be as specific as possible)

*Preferred Surgeon?:

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*Questions to surgeon:

*Diabetes or blood sugar problems:

*Thyroid Problems:

*Heart problems:

*Lung problems:

*Blood pressure problems:

*Kidney or Liver problems:

*Blood disorders:

*Previous or current history of cancer:

*HIV or AIDS:

*Nervous Breakdowns/Depression:

*Neurologic problems:

*Anaesthesia problems:

If you have answered YES to any of the above, please specify:

Have you had or do you have any medical conditions not mentioned above?:

*Have you been hospitalised, had surgery or received medical care within the past 12 months?:

If yes, when?:

If yes, what was the reason for this?:

*Do you have implants or any metal objects in your body?:

If yes, please specify:

*Do you have difficulty with healing or scarring?:

*Do you have any allergies to food, drugs, etc?:

If yes, please specify:

List all medications you currently take including dosage for each:

List all vitamins or food/nutritional supplements you currently take:

*Have you ever taken a MAO inhibitor such as Nardil, Marplan or Parnate?:

If yes, when was your last dose?:

*Have you ever taken an anticoagulant such as Coumadin, Heparin, or a daily Aspirin?:

If yes, when was your last dose?:

*Do you smoke?:

If yes, how much do you smoke?:

If yes, when did you last smoke?:

*Do you drink alcohol?:

If yes, how much do you drink?:

Do you take birth control pills, hormone replacement medication, or wear a hormone patch?:

Are you pregnant now?:

Are you planning any more pregnancies?:

When did you last deliver a baby? (Month & Year):

When did you last breastfeed? (Month & Year):

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Tips on taking Photos

Photos should show the front and both sides of each area. If someone else cannot take your photos, please use the timer function on your camera.

Face and Neck – Without glasses or make-up, hair pulled away from the face and forehead and no clothing or accessories around neck area.

Nose - Please take a picture of your nose and face from the front and both sides. Oblique pictures of your nose are also required as is a picture from below showing the nostrils.

Breasts - With your arms by your side so the surgeon can assess the degree of asymmetry or sagging that may be present.

Tummy, Thighs, Waist – Photos may be taken wearing underwear for these areas.

Intimate surgery – Photos are not required for Labiaplasty or Vaginal Rejuvenation.

Dental - Photo of your natural smile and another that shows your bite. Please use your fingers to part your lips so the dental specialist can see your bite clearly. If you have a dental report or X-rays please send these to us.

Email photos to private@stunningmakeovers.com