Out of Town Patient Form:
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Thank you for choosing Dr. Thomas P. Trevisani, M.D. for your cosmetic surgery needs.
We would appreciate you taking 5 minutes to complete this quick questionnaire.
If we can be of any further assistance, please do not hesitate to call us (407) 629-4100.

Step 1 of 3 - CONTACT INFORMATION

DOCUMENT UPLOAD
Upload a valid copy of your ID
Upload a valid copy of your ID*
Max. file size: 50 MB.
Submit your photos
How to take photos for Breast and Body
Have someone take a good set of photos taken in front of plain background - make sure that someone else takes the photos not you
(frontal view arms by your side, frontal view arms down, profiles and facing the wall)
How to take photos for Face
Have someone take a good set of photos taken in front of plain background : frontal view- without a smile and with a smile, and two profiles. For nose: make sure to include sub-mental view (nostril view); For eyes-- eyes wide open, and squinting.
Upload your photos*
Drop files here or

Max. file size: 100 MB.
Agree*
- I certify that the aforementioned information is true to the best of my knowledge and that I have not omitted anything that may affect the course of treatment by Thomas P. Trevisani, M.D.
- The preliminary evaluation fee is $100.00 plus surcharge and is applied toward the surgical procedure. Once the chart is evaluated - a patient will be contacted within 24-72 hours (business days) with preliminary surgery info I acknowledge and accept this.
Signature*
By signing below, I authorize Celebrities Choice Cosmetic Surgery to charge my credit/ debit card a full amount of $100.00 plus surcharge ( non-refundable).
Today's Date*
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Email
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Out of Town Patient Form:
All submissions are protected by SSL encryption.

Step 1 of 3 - CONTACT INFORMATION

*Please note you will need to upload a valid copy of your ID and submit personal photos for evaluation.

CONTACT INFORMATION

HISTORY AND PHYSICAL

DOCUMENT UPLOAD

Upload a valid copy of your ID

Submit your photos

How to take photos for Breast and Body

How to take photos for Face

Out of Town Patient Form: All submissions are protected by SSL encryption.

Step 1 of 3 - CONTACT INFORMATION

*Please note you will need to upload a valid copy of your ID and submit personal photos for evaluation.

CONTACT INFORMATION

HISTORY AND PHYSICAL

DOCUMENT UPLOAD

Upload a valid copy of your ID

Submit your photos

How to take photos for Breast and Body

How to take photos for Face

Out of Town Patient Form:
All submissions are protected by SSL encryption.