Surgeon: ____________ Date: ______________

Time: ____________ am/pm phone: ___________ address:__________________________________
_________________________________________
website: __________________________________

referred by: ________________________________
Certified by:
American Board of Plastic Surgery:[ ] yes [ ] no
Other: __________________________________________

Rating

• Patient referral list available: [ ] yes [ ] no

• Bedside manner:[ ] poor [ ] fair [ ] average
  [ ] above average [ ] excellent

• Communication skills:[ ] poor [ ] fair
  [ ] average [ ] above average [ ] excellent

• Attitude of staff:[ ] poor [ ] fair [ ] average
  [ ] above average [ ] excellent

• Appearance of surgeon:[ ] poor [ ] fair [ ] average [ ] above average [ ] excellent

• Office appearance:[ ] poor [ ] fair [ ] average
  [ ] above average [ ] excellent

• Questions all answered:[ ] poor [ ] fair [ ] average [ ] above average [ ] excellent

Overall Rating:[ ] poor [ ] fair [ ] average [ ] above average [ ] excellent

1. How long have you been performing breast reduction surgery? ____________________________

2. How many breast reductions do you perform each month? _______________________________

3. Which techniques do you perform? _____________________________________
   _____________________________________
   

4. What technique would you recommend for my needs and what key factors decide this? ___________________________________________
   ___________________________________________

5. Which general breast shape will I have post-operatively? [ ] cone-shaped [ ] sloped [ ] high, flattened and rounder [ ] other

6. Do you keep the nipple and areola complex attached via a pedicle or detach it completely?
   ____________________________________________
   ____________________________________________

7. How long does it take to perform the breast reduction surgery? ___________________________________

8. Do you have a video of the breast reduction procedure that I may check out? [ ] yes [ ] no

9. What is the overall cost of this procedure? ____________________________________________

10. Does this price include post-operative visits? [ ] yes [ ] no

11. Should I get a mammogram beforehand? ____________________________________________

12. What preliminary tests are required before surgery (i.e. CBC, Chem-7, pregnancy test, etc)
    ___________________________________________
    ___________________________________________

13. Will I be receiving a medications to a void list? [ ] yes [ ] no
    If not, have them check over our print out at www.breastreduction4you.com/medication_list.htm

14. Do you recommend Arnica Montana or Bromelain tabs (cosmeticsurgeryshop.com)?
    ___________________________________________
    ___________________________________________

15. Do you recommend that I take other supplements like vitamin C, Vitamin A, zinc, L-Carnitine, Alpha Lipoic Acid, etc?
    ____________________________________________
    ____________________________________________

16. Do you recommend a special diet or sensible diet balanced with whole grain carbs, protein and vegetables beforehand? What about low sodium, no caffeine, etc.
    ____________________________________________
    ____________________________________________

17. Will my procedure be covered by my insurance? _________________________________________

18. How much volume must be removed, on average, to qualify for insurance coverage? ___ grams___ cc

19. How much is expected for a down payment to hold my surgery date and when do you require the balance? ____________________________________________
    ____________________________________________

20. Do you finance? If not, which companies do you recommend? _________________________________

21. Will my procedure be performed in a hospital setting or an out-patient care facility?

22. If in a surgical center, is this facility accredited? If so, by whom? _______________________________

23. What type of anesthesia will be used? ___________________________________________
    

24. Do you use a certified anesthesiologist? ___________________________________________

25. Will I have to be catheterized? ____________________________________________
    

26. If so, will you wait until I am anesthetized to do so? ____________________________________________

27. What are the risks & complications for reduction mammoplasty?_______________________________
    ___________________________________________
    

28. What percentage of patients develop fat or skin necrosis? __________________________________

29. Have any of your patients developed fat or skin necrosis?___________________________________
    ___________________________________________
    

30. Are there any unforeseen problems associated with breast reduction that I should be aware of? ___________________________________________
    

31. If I have any complications will you be the surgeon on call should I have a problem?
    ___________________________________________
    ___________________________________________

32. Do I need an areolae reduction? How many centimeters post-op will my areolae be? ___________________________________________

33. Will you be using sutures, staples or tissue glue to close the external sutures? ___________________________________________
    ___________________________________________

34. Will you use permanent sutures such as Mersilene or Prolene? [ ] yes [ ] no ___________________________________________
    ___________________________________________

35. What happens if an internal suture "pops" or extrudes from my breast, what can be done?___________________________________________
    ___________________________________________

36. Will I have drains inserted? [ ] yes [ ] no If yes, where are they placed and when are they removed?
    __________________________________________
    ___________________________________________

37. How great will my pain be? What medications do you prescribe? ___________________________________________
    ___________________________________________
    

38. Do you encourage the use of a pain pump? ___________________________________________
    

39. When will I be able to shower again? ___________________________________________
    

40. What should I expect during recovery? _____________________________________________

41. Will there be a lot of swelling and bruising?____________________________________
    

42. How bad will my scars be?____________________________________________
    

43. Do you use Steri-Strips? [ ] yes [ ] no<</p>/li>

44. Do you recommend silicone sheeting or silicone for scars? ______________________________________

45. Can I go braless after I heal? Should I? ____________________________________________
    

46. What size do you think I will be post-op? ____________________________________________

47. May I see your breast reduction before & after photo album? [ ] yes [ ] no

48. Have you performed a breast reduction on anyone of your staff? May I speak to her? ____________________________________________
    ____________________________________________

49. Do you have a referral list so that I may speak to a few of your patients? [ ] yes [ ] no

50. Will I still have sensitivity in these areas post-operatively? ____________________________________________

51. Must I provide and bring the day of surgery, two front closure bras or a sportsbra. Where is the
    best place to purchase these bras; any particular brand names that you recommend? ____________________________________________
    ____________________________________________
    

52. How long will it be before I can lift objects over 5 lb? ____________________________________________

53. When will I be able to exercise and return to life as usual? ______________________________________

54. How long will it take to see my true results? ___________________________________________
    

55. What if I develop "dog ears" -- will you correct this problem? If so, at what cost to me? _____________
    ____________________________________________
    

56. Will I be able to breastfeed one day?________________________________________
    

57. If I need an additional surgery to correct significant asymmetry, what will the costs be and will I be responsible? ____________________________________________
    ____________________________________________
    

58. How long must I wait before having revision surgery?________________________________________

Notes:
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