Thank you for your interest in The Plastic Surgery Clinic! The decision to undergo an elective surgical procedure is a big one and we are here for you every step of the way. We're honoured to be considered as your surgical provider.

This Consultation Intake Form helps us to understand your goals and to streamline the consultation process. Your information will be securely stored in our Electronic Medical Records system, it will never be shared.

First Name *

Last Name *

Date of birth *

Phone *

Email *

I want email & SMS updates from the doctors and clinic on pricing, special offers, and event invites. I know I can unsubscribe at any time.

Address *

City

Province

Postal code

Have you had a consultation or surgery with us in the past? *

Yes

How did you hear about our clinic? *

Friends/Family
Word of Mouth
Instagram/TikTok/Social Media
Google Search
Online Ad
Doctor
RealSelf
Other
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Height (ft) *

Weight (lbs) *

Have you been pregnant in the past year? *

Yes

Pleas let us know when you delivered your baby. *

Have you breastfed in the past year? *

Yes

Please let us know when you stopped or plan to stop breastfeeding. *

Which surgeon would you like to see? *

Dr. Frank Lista
Dr. Jamil Ahmad
Dr. Ryan Austin
Dr. Diego Pereira
No preference/Soonest Available
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Which procedure are you interested in? *

arm lift
arm liposuction
BodyTite
body contouring
body contouring after weight loss
Brazilian butt lift
breast augmentation
breast augmentation with fat transfer
breast implant revision
breast lift
breast reduction
brow lift
buccal fat removal
CoolSculpting non-surgical fat reduction
ear pinning
excess skin removal
eyelid lift
facelift
FaceTite and AccuTite
hips liposuction
hymen repair
inverted nipple correction
labia reduction
leg and thigh liposuction
liposuction
male breast reduction
mini facelift
mini tummy tuck
minor procedures
mommy makeover
multiple procedures
rhinoplasty
non-surgical beauty procedures
scar revision plastic surgery
surgical lip lift
tummy tuck
tummy liposuction
thigh lift
vaginal tightening
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Please list any additonal procedure(s) you are interested in:

Have you had this procedure in the past? *

Yes

When did you have this surgery? *

Have you had cosmetic surgery in the past year? *

Yes

Please let us know what surgical procedure you had and when. *

When is your ideal time for surgery? *

Within 1 month
1-3 Months
3-6 Months
6-12 Months
Not Sure
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Please attach any applicable photos and/or documents:

Your surgeon will provide you a quote for the procedure after your consultation. Please note that your quote will be valid for 6 months. If you are interested in booking surgery after the 6-month period, our patient coordinators will assist you in booking an appointment with the surgeon to provide an updated quote.

Additional Details

If any of the following applies to you, a patient coordinator will be in touch for further details:

If you have had a previous breast augmentation and currently have implants, please be advised that we require the implant information prior to booking a consultation. You can often get this information from your original surgeon or the implant provider (i.e. Mentor, Allergan).

If you have had a previous rhinoplasty, please be advised that we will require photos of the left, right, frontal, and basal view of the nose, and a list of your main concerns.

Our clinic is wheelchair accessible. Please advise if you have any mobility requirements:

Yes

Please provide details

By submitting, you authorize The Plastic Surgery Clinic to send emails and text messages with offers and other information. Message/data rates apply. Consent is not a condition of purchase.