Doctor Finder:  Submit Your Price
You have read the legal disclaimer and agree to the terms and conditons. The information you provide will assist your surgeon in evaluating your personal surgical needs. The more specific and exact your information is, the more accurate and meaningful your counter-quote will be [Currently servicing Southern California].
*Please note that the questions marked with an asterisk are of major
  significance and must be answered.
 
Patient Information [required]:
Please note that the following information will assist your surgeon in evaluating your personal surgical needs. The more specific and exact your information is, the more accurate and meaningful our counter-quote will be.
 *First Name
 *Last Name
*Gender  Male  Female
*Address
*City
*State    *Zip Code
*E-mail
*Phone #
Occupation
How Many Children
Date of Birth [mm/dd/yy]
Marital Status Married    Single      
Height [feet] [inches]
Weight [in pounds]
Body Frame
 Muscular/large   Medium build
 Small Petite  
Ethnic Origin
 Asian      European  
 Mid-Eastern    Hispanic 
 African American   Other
       
The Bottom Line - Quick Form
*Select the surgery(ies) you are interested in and name your price:
1.
      for $
2.
      for $
3.
      for $
4.
      for $
5.
      for $
Date you would like to have this procedure?
[mm/dd/yy]
For the most accurate opinions regarding potential surgery, please complete as much information in this form as possible, including the information below.  When you are finished, simply click the "Submit" button below, and your request will be processed.  You will receive an email with the following information for each procedure:
 
The contact information for the closest doctor to you on our network who is willing to perform the procedure at your requested price.
 
AND
 
The lowest-priced doctor on our network for your requested procedure.
 
AND
 
The 3 closest doctors on our network who can perform your requested procedure.
 
          
 
 


It would be of great assistance to your surgeon if you would answer the following questions pertinent to the areas of your body where you wish to have cosmetic surgery:
 
Skin
Which one of the following most accurately describes your characteristics?
Blue eyes/Blond Hair/Light-fair skin tone
Hazel-Grn-Blue eyes/Brown-black hair/ 
Light-fair skin tone
Brown Eyes/Brown-Black hair/
Light brown-natural tan skin
Brown-Black Eyes/ Black hair/Brown color skin
Brown-Black eyes/ Black hair/ Brown-Black skin
Scalp
Do you suffer from hair loss?
Do you suffer from baldness?
Brows
A) Functional Questions
Do you experience asymmetry of brows at rest?
Do you experience weakness of one brow in 
comparison to the other?
B) Aesthetic Questions
Do you experience brow heavy and full?
Do you experience angles of the eyes fallen?
Eyelids
A) Functional Questions
Do either of your eyelids remain 
open after sleep?
Do either of your eyelids at rest hang down too far,
lower than most?
B) Aesthetic Questions
Do you experience excess skin?
Do you experience too much fat protruding 
through your eyelids?
Face
A) Functional Questions: Do you suffer from any of these:
Frequent acne
Asymmetric smile
Jawls
B) Aesthetic Questions: Do you suffer from any of these:
Acne scars
Deep facial lines
Age spots
Moles
Deep lines on the forehead
Deep fold extending from edge of nose
to edge of lips
Nose
A) Functional Questions: Do you suffer from any of these:
Difficulty breathing
Frequent nose bleeds
Previous fractures
Previous trauma to nose
B) Aesthetic Questions: Do you feel like any of these:
Your nostrils are too wide
Your bridge is too wide
Your bridge is too deep seated
Your bridge is crooked or deviated
Your nose is asymmetrical positioned
Your tip is too large and bulbous
Your tip is pointing too far down
Your tip points too far up
Neck
Do you feel that your neck has too much fat
Do you feel that your neck has too much 
hanging skin
Do you feel that your neck has too many 
skin/muscle bands
Breast
Date of last mammogram [mm/dd/yy]
Results
Your breasts are hanging too far down
Your breasts are too big
Your breasts are too small
Your breasts are asymmetric
Your nipples are too low
Abdomen
Number of pregnancies
Number of child births 
Age of children 
Does your abdominal skin have any stretch marks
small amount
medium amount
large amount
Are your abdominal wall:
tight and muscular
lax and weak
mild laxity with slight amount of fat
medium laxity with large amount of fat
What areas of your body are of concern to you?
Body Fat Breasts Face 
Hair         Skin
Select procedure(s) you are interested in (hold down control key to select multiple procedures):

     
Select cosmetic surgery you have had (hold down control key to select multiple procedures):

     
Are you happy with the result of your past cosmetic surgery?
Yes No
General Health Questions
Have you ever had a blood transfusion?
Yes No, 
If yes approx. date
Do you smoke/use:
Cigarettes  Yes No   
        -- How many packs per day
Pipe  Yes No
Chewing tobacco Yes No
        -- for how many years
When was your last tobacco use?
Today  Months ago   Years ago
Do you drink alcoholic beverages?
Yes No 
-- What kinds 
How many ounces per week?
Do you take aspirin at all? 
    Yes No
Do you take vitamins on a daily basis? 
    Yes No
Do you take any herbal remedies on a daily basis?
    Yes No
Past Medical and Surgical History
Suffered any medical illnesses? 
If yes, please list
Had any surgeries before? if yes please list
Ever been hospitalized? if yes, when & why
Are you now or have you ever been under the care of a psychiatrist or psychologist?
Yes No
Do you or have you ever taken any medications prescribed for your mood, depression, excess anxiety or thought patterns prescribed by your psychiatrist or doctor?
Yes No
Medication History
Are you allergic to any medications? please list
Are you currently taken or have you ever taken any medications for more than two weeks? please list

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