ADVANCED CENTRE FOR PLASTIC SURGERY :::::::::::::::::::::::::::::::::::::::: JAMES A. MATAS, MD

Complimentary Personal Analysis and Evaluation

When it comes to plastic surgery, no two humans are created exactly alike! For us to give you the best advice, we need to assess individual factors as they relate to your overall goals and objectives. You may consider some questions personal, but your answers help shape our suggestions and allow us to communicate most effectively.
THIS EVALUATION IS NOT DESIGNED TO REPLACE A ONE ON ONE CONSULTATION AND EVALUATION BY AN EXPERIENCED PLASTIC SURGEON, but should give you some general direction as to the procedure or combination of procedures you may be a candidate for, along with some idea of financial cost.

1. Self-improvement Interest(s)
(check all that apply)
Facial Procedure (facelift, necklift, forehead lift, eyelid surgery)
Breast Procedure (breast enhancement, breast lift, breast reduction)
Body Contouring (tummy tuck, liposuction)
Non-surgical treatments (Skin care, Injectable fillers, Botox)
Other (please specify details)

2. Rank Areas of Interest
(please rank areas of interest checked above in order of your personal priority)

Facial Procedure
1 2 3 4 5

Breast Procedure
1 2 3 4 5

Body Contouring
1 2 3 4 5

Non-surgical treatments
1 2 3 4 5

Other
1 2 3 4 5

3. Goals and Objectives
Please describe the type of improvement you are seeking and be as specific as possible. If you are seeking improvement to your breasts, for example, would you like to increase your cup size, increase firmness, lift the breast, etc.

Personal History
If your problem areas are as a result of pregnancy/nursing, weight fluctuation, birth deformity or family feature common to you and your relatives, please indicate here. This helps us to better assess important factors that contribute to your appearance.

Success
A procedure can be satisfactory according to the standards of our industry, but this is no guarantee that patient satisfaction will be achieved, since there are a variety of personal and psychological factors that contribute to this. What changes would you like to see once your surgery and recovery has been completed for you to consider your experience a success? Increased self-confidence and esteem, decrease in dress size, better fit in clothing and acceptance of family members are some examples for you to consider.

4. Time Frame
If a certain time frame needs to be considered for your procedure, please indicate here. For instance, if you will need to be totally recovered by your wedding day, or have two week’s vacation already reserved, let us know. The more information we have regarding your plans, the better we will be able to help you.

5. Priorities
It is recommended that you evaluate 2 or 3 plastic surgeons and their practices before choosing, so we assume you are “shopping around”. Since you will have to evaluate us against other practices, please check your top 3 considerations in choosing a plastic surgery practice.

Estimated cost
Physical location/convenience
Quality of past results obtained
Recommendation of former patient
Ability of meet your personal deadlines
Qualifications/experience of surgeon
Personal attention
Caring support staff

6. Budget
What is your approximate budget?

Under $1,000
$1,000 – 3,000
$3,000 – 5,000
$5,000 - 10,000
$10,000 +
I haven’t established a budget or I would rather not disclose it at this time

7. Financing
In addition to accepting cash, check and all major credit cards as payment for services, we offer a financing program that allows you to make monthly payments rather than pay one payment in full. Please indicate whether you MAY need financial assistance in order to have your procedure.

Yes
No
Maybe. It depends on outside factors that have not yet been determined.

8. Final comments
Is there anything else you would like us to know about before we begin?

9. About you

First and last name
Address
City
State or Country
Email address
Phone
Phone Type	Work Home Cell
Age Range	<21 21-35 36-44
	45-54 55-69 70+
Gender	Male Female

Have you ever had plastic surgery?
Yes
No

How did you find us?

Referral of friend/co-worker

Internet (list search term or website link if you remember)

Professional medical society (ASPS or ASAPS)

Other (please list source)

Important note: The information you provide on this evaluation is strictly confidential and will not be used for any purpose other than your assessment as a potential patient.

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