Registration Form for Plastic Surgery Consultations

Plastic Surgery Consultations Registration Form

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Title*

First Name*

Surname*

Email*

Mobile Number*

Address*

Street Address Address Line 2 City State Post Code Country

Date of Birth*

DD slash MM slash YYYY

Sex*

Height in cm*

Weight in kg*

Your Occupation

Next of Kin - Name*

Next of Kin - Relationship to you*

Next of Kin - Mobile*

How did you hear about Coco Ruby?*

Friend / Family

Google Search

Social Media

GP Referral

Other (please specify)

Other (Please specify)

What procedure(s) are you interested in?*

Asymmetry / Tuberous Breast Correction

Arm Lift (Brachioplasty)

Breast Implants (Augmentation)

Breast Implants with Lift (Breast Augmentation Mastopexy)

Breast Lift (Mastopexy)

Breast Reduction (Reduction Mammoplasty)

Implant Revision (Removal and Replacement of Implants)

Removal of Breast Implants

Tummy Tuck (Abdominoplasty)

What is the most important thing we are trying to achieve with your breast implant surgery?*

What do we not want/what do we need to avoid ?*

Medicare

Private Health Insurance

I do have Medicare*

Yes

Medicare Card Number*

Individual Reference Number*

Health Fund*

Membership Number*

Private Health Insurance Number*

Valid To*

Level of Cover (Bronze, Silver, Gold)*

I agree

“Coco Ruby Plastic Surgery respects your personal information and right to privacy. The personal information collected in this Patient Registration Form (including your name, address, email, phone number and medical history) is used for the purpose of providing treatment to you and to contact you when necessary. Your personal information will be collected, handled and stored securely by Coco Ruby Plastic Surgery in line with privacy law. Disclosure of your personal information will not be made to any person not involved in either your treatment or the administration of this practice, without your prior consent. A copy of our Privacy Policy is available at Reception. By completing and returning the Patient Registration Form, you acknowledge and agree to your personal information being collected, used and stored in the manner stated above”

Please attach your GP or Specialist referral

Drop files here or

Max. file size: 20 MB.

Is there any possibility you could be pregnant at the time of filling in this form?*

Yes

Do you have any children?*

Yes

Childrens Age/s*

Add a new line for each child.

Plans for future children?*

Yes

Do you smoke? (inc. Vape)*

Yes

Would you be willing to quit smoking prior to and post your operation?*

Yes

Please list any Medications you currently take, including anabolic steroids and hormone replacement*

List any vitamins / supplements / holistic medicine you take, if any*

Do you have any allergies? (if yes, please list them and what reaction you have.*

Family History: Please include any history of cancer, malignant hyperthermia, diabetes etc*

Please list any procedures you have had in the past, including any reactions you have had to the anaesthetic if any occurred*

Medical History: Please include any hospitalizations, ongoing monitoring, reasons for medications*

Do you currently or have you ever seen a medical specialist (including another plastic surgeon)? If so, please list who and what for*

Have you ever had and clinical dermal procedures such as Laser, filler, PDO threads If yes, please list them and the approximate last date of treatment*

Breast Surgery Patients only

Did you breast feed your children?*

Yes

How long did you breast feed? (months)*

Have you ever had a mammogram?*

Yes

Approximate date of your last mammogram?*

What is your current bra size?*

What is the largest bra size you have ever worn?*

What is the smallest bra size you have ever worn?*

What bra size would you like to achieve?*

Have you ever had any lumps in your breasts?*

Yes

Please provide additional comments*

Have you ever had any surgery on your breasts before?*

Yes

Please state when and what procedure was performed and which surgeon performed the procedure*

Do you have any family history of Breast Cancer?*

Yes

Please state your relationship to the person(s)*

Body Contouring Patients Only

Where any of your children delivered via Caesarean section*

Yes

Have you ever had surgery on your stomach?*

Yes

Please advise what surgery took place, approximate date of surgery and the surgeon who performed the procedure*

What is your goal weight range?*

What exactly are you trying to achieve with surgery?

How long have you considered having surgery?

Why do you think you have waited until now?

What is the main reason why you would or wouldn't proceed with surgery?

If appropriate for you, when would you like to proceed with your surgery?

In achieving your goal, how will that make you feel?

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Opening Hours Facebook | Instagram | You Tube

Monday - Friday

9.00 am – 5.00 pm

Address

759 Burwood Road, Hawthorn East, Victoria 3123

Street parking is available nearby for up to 2 hours, plus an onsite parking lot.

Phone

New Patients (03) 8849 1400
Reception (03) 8849 1400

Email

reception@cocoruby.com.au

Fax

(03) 9429 8456

Let’s Get Started

Make an enquiry

Please fill out your details and we will be in touch. If you would like to leave any feedback please email feedback@cocoruby.com.au

First Name*

Last Name*

Phone*

Email*

I'm Interested In*

Would you like us to call you?*

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Comments

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Plastic Surgery Consultations

Plastic Surgery Consultations Registration Form

Breast Surgery Patients only

Body Contouring Patients Only

Make an enquiry

Book a Consultation

Hawthorn East

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