We do NOT provide quotes without the benefit of physical exam/ or preliminary evaluation for out of town patients. All inquiries re/ quotes will be redirected to our Appointment reservation/ Cancellation policy. Out of town patient form,all submissions are protected by SSL encryption. Thank you for choosing Dr. Thomas P. Trevisani, M.D. for your cosmetic surgery needs. We would appreciate you taking a minute to complete this quick questionnaire. If we can be of any further assistance, please do not hesitate to call us (407) 629-4100.Your Email* Enter Email Confirm Email Name* First Last DOB* MM DD YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Your Phone Number*HOW DID YOU HEAR ABOUT US? I am a former Patient T.V. Commercial Talent Agency Speaking Engagement Magazine Ad Doctor Referral RealSelf Online Radio Station Speaking Engagement, please specify:Talent Agency, please specify:Doctor Referral, please specify:Online, please specify:What Magazine did you see our Ad in?Which of the following radio station? 88.7 100.3 103.1 105.9 95.3 101.9 104.1 106.7 98.9 102 105.1 107.7 HISTORY AND PHYSICALReferred byFamily DoctorState the specific reason(s) why you made an appointment:Have you consulted with any other physician regarding this problem(s)?*yesnoHeight*Weight*Weight loss or gain in the past year*yesnoPlease enter weight loss or gain in the past yearDate of your last physical MM DD YYYY Did you have an EKG?*yesnoChest X-ray*yesnoDo you or any family member have a history of the following conditions? Tuberculosis High blood pressure Cancer Lung disease Diabetes Asthma or emphysema Kidney disease Epilepsy Heart disease Bleeding disorders Please list any serious illness or injuries that you had or have. Please include dates:Have you had any surgical procedures?yesnoHave you had any significant complications from surgery or anesthesia?yesnoPlease list any and all surgical procedures that you have had. Be specific.Date MM DD YYYY ProcedureDoctorAnesthesia (General or Local)GeneralLocalDate MM DD YYYY ProcedureDoctorAnesthesia (General or Local)GeneralLocalDate MM DD YYYY ProcedureDoctorAnesthesia (General or Local)GeneralLocalPlease list all medications, which you are now taking including birth control, water pills, heart medications, sleeping pills, hormones, aspirin, and any other over the counter drugs:Are you pregnant?*yesnoDate of your last menstrual period MM DD YYYY Do you smoke?*yesnoHow much do you smoke per day?Do you drink coffee/tea?*yesnoHow much coffee/tea do you consume each day?Do you consume alcoholic beverages? (including beer/wine)*yesnoHow much do you consume daily?Are you or have you taken any mind-altering drugs?*yesnoPlease specifyDo you have any allergies to food, plants, or medications?*yesnoPlease specifyHave you or any member of your family ever reacted poorly to being put to sleep?*yesnoDo you require large amounts of anesthesia for medical or dental procedures?yesnoHave you ever had a reaction to Novocain or Lidocaine?*yesnoAre you allergic to adhesive tape?*yesnoDo you bleed easily?*yesnoAre you a “poor” or “slow” healer?*yesnoDo you form keloids?*yesnoHave you ever taken steroids?*yesnoDo you get short breath during walking?*yesnoDoes your religion prohibit transfusions?*yesnoHave you ever been advised or under the care of a psychiatrist or psychologist?*yesnoHave you or do you have any illness or disorders of the following? Please check box if “YES” Brain (strokes, seizures) Nose, Throat, Sinuses Breasts Stomach Blood Liver Lungs (asthma, emphysema) Heart or Blood Vessels Intestines Bones & Joints Face(paralysis) Eyes (glaucoma, dryness, tearing) Ears(hearing loss or impairment) Reproductive system Arms/Legs Endocrine or Diabetes Urinary Tract Scarlet/Rheumatic Fever Skin (eczema, hives, cysts, boils) Please explain: Upload a valid copy of your IDUpload a valid copy of your ID*Submit your photosPlease select procedure for the procedure you are uploading photos for.* Breast and Body Face 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 Today's Date* MM DD YYYY * 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 $50.00 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 $50.00 ( non-refundable). PhoneThis field is for validation purposes and should be left unchanged.