Please fill in and submit the following form. You are welcome to write N/A if the question is not applicable.
The following genetic heritage question is relevant to the external and internal anatomy of the nose
Genetic heritage of Mother:
Genetic heritage of Father:
Name of Private Health Fund Provider:
Does your insurance cover surgery in a private Hospital?
—Please choose an option— Yes No
Have you had any other consultations for rhinoplasty assessment?
—Please choose an option— Yes No
How many?
—Please choose an option— 1 2 3 4 5 6 7 8 9 10+
Have you had any other cosmetic procedures?
—Please choose an option— Yes No
Have you had any fillers in your nose?
—Please choose an option— Yes No
Have you had any previous rhinoplasty surgery?
—Please choose an option— Yes No
Have you returned to the surgeon to discuss revision surgery?
—Please choose an option— Yes No
Will you allow Dr Dunlop to contact the previous surgeon for operation details?
—Please choose an option— Yes No
What bothers you most about your nose?
What would you like your nose to look like after surgery? (you may upload a photo of a person on the internet / my website / your relative or digitally enhance your own photo using a free app such as Facetune).
How will rhinoplasty surgery change your life?
Are you a smoker?
—Please choose an option— Yes No
Do you vape?
—Please choose an option— Yes No
Do you ever take recreational drugs including marijuana?
—Please choose an option— Yes No
Does this include cocaine?
—Please choose an option— Yes No
Do you take following drugs?
Please list your medications including health supplements.
Do you have any medication allergies?
Thank you for completing this application. It is designed to save you time and money if you do not proceed with Dr Dunlop. Most senior surgeons subspecialise and we need to make sure you will be looked after by the right surgeon.
8/176 Fox Valley Road Wahroonga, NSW 2076
