E-Consult: Breast

Read the instructions here
Prepare the necessary information as described in the instructions.
Fill out the E-Consult form. (* = required field)
One of our surgeons will review your E-Consult and reply as soon as possible.

PERSONAL DETAILS Name: *
E-mail: *
Age: Years

QUESTIONS What's your height? Meter
What's your weight? KG
Is your weight stable? Yes No
Hip measurement? Centimeter
Do you smoke? Yes No
If yes, how much do you smoke?
Do you consume alcohol? Yes No
If yes, how much alcohol?
Do you have healthproblems?
If so, describe:
Have you had any type of surgery before?
If so, describe:
Are you taking any medication (including herbal)?
If so, specify which:
Are you allergic to certain medication (including herbal)?
If so, specify:

QUESTIONS FOR FEMALES Number of pregnancies?
Number of live births?
Are you pregnant now? Yes No
Are you planning pregnancies in the next 6 months? Yes No

Any history of breast cancer in your family? Yes No

What your current cup/bra size?

Chest circumference?
Distance from the Left Sternal Notch to the Nipple?

Distance from the Right Sternal Notch to the Nipple?

Tell us what cup/bra size you desire, after the procedure?

YOUR PICTURES Picture 1 (front arms down)
Picture 2 (front arms raised)
Picture 3 (angle left breast)
Picture 4 (angle right breast)

EXTRA INFORMATION If there's any extra information you think we need to know about you in order to make a good review of your specific case, please specify here:

Important

Please beware that, although this E-Consult can give you a some basic information about the procedure you are considering, it can't replace a consultation in person with one of our surgeons.

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E-Consult Instructions

Manual to take the necessary pictures Below you find an example of the four necessary pictures for your breast e-consult. Views of the breasts must be topless! There is no use in sending us pictures of your breasts wearing a bra. Pictures should be taken from the lower neck down to the navel.
Picture 1: Front The first picture is a frontal view, keep your arms down but slightly away from your body.
Picture 2: Front arms raised The second picture is a frontal view, just like the first picture, but this time raise your arms.
Picture 3: Side view left breast The second picture is a 45° angle view to demonstrate a side view of your left breast (closest to the wall).
Picture 4: Side view right breast The third picture is a 45° angle view to demonstrate a side view of your right breast. This picture is the same as the third but from the other side.

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