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Consultation Form

Please answer all questions
Patient Name:
E-mail Address:
Phone Number:
1. Please indicate how much weight you have lost over the past 2 years.
a. How much did you weigh prior to loosing weight?

b. What is your current height, and weight (lbs.)?

b. Do you anticipate any further weight loss? If so, how many (lbs.) and by what date?
c. By what method do you anticipate further weight loss?
d. Do you have any body contouring surgery scheduled elsewhere? If so what date?
e. Name, Address, and Telephone number of your bariatric surgeon. Please indicate if you have had any post surgical complications, hernia, etc.
f. Please provide a list of personal physicians including their Address, and Telephone Number. And indicate your primary care giver or specialist.
g. Have you experienced Comorbidities prior to your recent weight loss? (Push your CTRL key to select additional choices. Macintosh users press your Apple key.)
h. Have you experienced Comorbidities after bypass surgery? (Push your CTRL key to select additional choices. Macintosh users press your Apple key.)
i. Do you have any other significant medical or psychiatric conditions?
2. Your body contour concerns and priorities. Please check your specific areas of interest.
Liposuction
W/ Breast Augmentation
W/ Breast Reduction
a. Please select your interests in improving body features and rank them in numerical order (with 1 being the most important).
1      2      3      4      5      6      7
Face, Neck
Arms
Breasts
Abdomen, Hips
Back Flanks, Pubic
Region, Buttocks
Outer Thighs
Inner Thighs
3. Have you had any prior body contouring surgery?
Liposuction
Excisonal Surgery
a. In what areas was your prior surgery concentrated on?
Face, Neck
Arms
Breasts
Abdomen, Hips
Back Flanks, Pubic Region, Buttocks
Outer Thighs
Inner Thighs
b. Were you satisfied with the results
of your prior surgery?
c. Have you considered or started the process of legal claims for damages for prior operations?
d. Please specify the location of any significant scars that you may have.
Face, Neck
Arms
Breasts
Abdomen, Hips
Back Flanks, Pubic Region, Buttocks
Outer Thighs
Inner Thighs
None
e. Are you considering surgery by Dr. Hurwitz?
Yes
No
f. Please send any photos of yourself that you think would be helpful.



4. Do you have any further questions or concerns regarding surgery and procedures?

MessageOur Staff

I honestly never thought of myself as a serious candidate for elective surgery ... but I’m already feeling and looking so much better. Jill's Story

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Pittsburgh (Main) Office

3109 Forbes Ave
Ste 500
Pittsburgh, PA 15213

Open Today 8:30am - 5:00pm

All Hours Directions (412) 802-6100

Pittsburgh (Main) Office

3109 Forbes Ave
Ste 500
Pittsburgh, PA 15213

Open Today 8:30am - 5:00pm

All Hours Directions (412) 802-6100