How long have you been considering breast augmentation?Less than a year1-2 years2-5 years>5 years
What are your biggest concerns about breast augmentation?Quality of resultCostPossibility of revisionLongevity of resultPain/recovery
Do you have any friends who have had breast augmentation surgery?YesNo
Have you had any other surgical consults?
Do you have any special events coming up for which you would like to ‘Elevate Your Look?
If you answered yes above, what kind of event?
When thinking about your desired outcome from breast augmentation, rank the following descriptors in order of importance to you (1-5, 1 most important)
Choose the profile that best represents your desired look (pick A, B, C or D):
When thinking about your ideal surgeon, please rank the following in order of importance to you (1-8, 1 most important):
Surgical Experience / Number of operations performed
Surgical Training / Board Certification in Plastic Surgery
Quality of Staff
Recommended by my physician/friends/family
What resources have you used in thinking about breast augmentation?
RealSelf.comAmerican Board of Plastic Surgery (www.abplsurg.org)American Society of Plastic Surgery (www.plasticsurgery.org)Other
If other, please describe:
How would you describe your lifestyle?
Highly ActiveAthleticBusy MomBody BuilderSingleMarriedWorkaholicTravelerSocialEasy GoingCompetitiveMake my own schedule
What time frame do you have in mind for completing your enhancement surgery?
ASAPIn the next few monthsWithin a yearStill just looking at my optionsIn time for an eventIn coordination of time off of work
What other information are you interested in to help you with your decision?
Safety / Risk informationCost / Financing optionsWhat to expect in recovery (time off from work, movement, restrictions, pain)New silicone breast implant technologyImportance of Board Certification in Plastic Surgery
Please provide your information below:
Your Name (required)
Your Email (required)
Your Phone Number
Any questions or comments?
How do you prefer to be contacted:
EmailPhoneI will reach out when I'm Ready