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Plastic Surgery Client Form

Welcome to The Radiance Space

Please take a moment to complete this medical history form. The information you provide is essential for us to assess your suitability for surgery and ensure your safety. All details will be kept confidential.

Best regards,

Sabrina Girotto

Full name*

What surgery was performed and which areas were treated?*

Is there any area where liposuction was performed? If yes, which area?*

Surgery date*

Day

Month

Year

Type of anaesthesia*

Length of hospital stay?*

Was there any complication? If yes, which one?*

Do you still have drains in place?*

Yes

Liquid coloration*

When is the scheduled day for drain removal?*

Day

Month

Year

Do you still have stitches?*

Yes

When is the scheduled day for stithes removal?*

Day

Month

Year

Have there been any episodes of seroma? *

Yes

How it happened? How long ago? Please explain.*

Are you experiencing difficulty breathing after the surgery? If yes, at what time of day or during which part of your routine do you feel this difficulty?*

Do you experience continuous pain? If yes, please explain.*

Do you experience pain during movement? If yes, please explain.*

Have you made any dietary changes due to the surgery, either before or after? If yes, which one?*

Are you wearing a compression garment?*

Yes

Not recommended

Are you using the compression board?*

Yes

Not recommended

Are you wearing compression stockings?*

Yes

Not recommended

Are you satisfied with the results of the surgery?*

Yes

Not sure yet

Is there any area you would like me to pay more attention to?

Is there any additional information you would like to provide?

Find Us

Unit 2/62 Pacific Parade

Dee Why NSW 2099, Austrália

Enquiries

Tel: +61 452 583 776

Email: contact.sabrinagirotto@gmail.com

Working hours

Monday 9am - 6pm

Tuesday 9am - 6pm

Wednesday 9am - 6pm

Thursday 9am - 7pm

Friday 8am - 5pm

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