Breast Revision Questionnaire

First Name* This field is required.

Last Name* This field is required.

Email* This field is required.

Birthdate (MM-DD-YYYY)

What is your current height and weight?

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

Please list all past breast surgeries.

Where are your incisions placed?

What type of breast implants do you have?

What size is your current implant?

Where is your current implant placed?

Please upload a copy of your implant card here.

What did you really like about your first procedure?

What are your current concerns about your breasts?

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

Do you have children?

What are you looking for in breast results?

Use our secure upload tool to submit your photos for review, please see guidelines below for instructions.

View 1 of 5

View 2 of 5

View 3 of 5

View 4 of 5

View 5 of 5

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.

This field is required.

Submit

*Use our secure upload tool to submit your photos for review.

If you have any questions or concerns, please don't hesitate to contact our office at (737) 787-7338.

Breast Revision Questionnaire

Cocktails & Curiosity 2023