Breast Augmentation Consultation Form
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1. First, please tell us a bit about yourself.
First Name:
*
Last Name:
*
Date of Birth (MM/DD/YYYY):
*
Date Format: MM slash DD slash YYYY
2. Have you ever had cosmetic surgery before?
Have you ever had cosmetic surgery before?
*
Yes
No
2a. Please specify:
Please specify:
*
3. Do you have any pre-existing medical conditions?
Do you have any pre-existing medical conditions?
*
Yes
No
3a. Please provide more information:
Please provide more information:
*
4. Do you smoke?
Do you smoke?
*
Yes
No
5. When would you like to get the procedure done?
Within what time frame are you looking to have the augmentation performed?
*
Within the next 3 months
Within the next 6 months
Within a years time
Undecided, only inquiring at this time
6. What is your main reason for wanting a breast augmentation?
What is your main reason for wanting a breast augmentation?
*
Increasing cup size
Correcting reduced breast volume post-pregnancy
Correcting imbalance in size or symmetry of breasts
7. Do you have a preference between one of the two types of implants?
Do you already have a preference between one of the two types of implants?
*
Saline
Cohesive Gel
Unsure
8. Did you know that Westmount Institute uses Vectra Technology?
Did you know that Westmount Institute uses Vectra Technology?
*
Yes
No
9. What is the best time of day to book your consultation?
What is the best time of day to book your consultation?
Morning
Afternoon
Email:
*
Phone Number:
*
What is your preferred method of contact?
*
Email
Call
Text
