Pre-Consultation Questionnaire

Breast Augmentation Questionnaire

Please help us prepare for your upcoming breast augmentation consultation by answering a few questions ahead of time.

First Name *

Last Name *

Email *

Birthdate

Phone

Patient Type

What is your current height and weight?

What is your current BMI?

Do you smoke/use tobacco, marijuana, or vape?

Who referred you to Dr. Piazza?

Do you have a timeframe for surgery or a timeframe that you need to be recovered by?

Have you had any breast procedures in the past? If yes, please list them.

What did you really like about your breasts?

What are your current concerns about your breasts? *

Have you ever had any changes in breast shape, size or firmness?

If so, when did this begin?

What is your current bra size?

Do you have children? If yes, how many?

Did you breast feed?

Were children born before or after your breast surgery?

What are you looking for in breast results? *

Do you have any current medical issues we need to be aware of? (Thyroid, High Blood Pressure, Diabetes)

By submitting this form, you agree to be contacted by phone, email, or text, and that any associated call may be recorded for quality and training purposes.

Breast Augmentation Questionnaire

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