Request for evaluation

Last name* First name Your profession

Email* Phone number

Do you have any known diseases?

Do you have any drug allergies?

Do you have any known psychological problems (anxiety/depression)?

Do you smoke? If so, how much?

Are you taking medication? if so, which ones?

What I don't like with my nose:

What I want to achieve as a result:

What are my expectations for this surgery?

Have you ever had nose surgery?

Have you ever had a nose trauma?

Do you have a obstructed nose?

How much time do you spend a day thinking about your nose? <1h 1-3h >3h

How long have you been thinking about the intervention for which you came to consult?

Is there an element or opportunity that motivates you in this process?

Do you have a relative who supports you in your project?

Is there anyone in your relatives who is hostile to this approach?

What aesthetic medical or surgical intervention(s) have you ever had?

Please put photos of your nose in different views.
Front, right profile & left profile, right oblique & left, bottom view & from above.

Authorized formats: .jpg, .jpeg, .png, .gif, .pdf

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Request for evaluation

before consultation