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Cosmetic Surgery New Referral Letter
Step 1 of 2
50%
"Thanks for visiting Qoctor, the online doctor.
First, we need to go through a few questions.
This will take 3 to 5 minutes, depending on your needs"
So, you’d like to see a plastic surgeon to discuss cosmetic surgery?
*
Yes
No
Please select the area(s) of your body that you wish to discuss with the specialist (you can select one or multiple options, if applicable)
Face
Eye area/brows
Ears
Nose
Arms
Breasts
Abdomen (tummy)
Thighs
Full body (due to weight loss)
For many procedures it is helpful for us to have some information about your height and weight. Please enter your height and weight in the following fields
Height (cm)
*
Weight (kg)
*
BMI
All surgical procedures are associated with potential risks and complications. These risks should be discussed thoroughly with your specialist before you proceed with any treatment.
*
Do you understand this advice?
Yes
No
Specialists Details
Specialist Name
*
Specialist Address
*
Specialist Telephone Number
*
Specialist Fax Number
GP's Details
GP's Name (if applicable)
GP's Address
GP's Telephone Number
GP's Fax Number
Special Notes
To complete your specialist referral letter , we need to obtain your medical history
Please select any conditions from the following list that apply to you now, or have applied to you in the past (leave blank if none apply)
Hypertension ( high blood pressure)
Heart disease
Stroke
Asthma
Thyroid disorder
Type 1 Diabetes
Type 2 Diabetes
Anxiety/depression
Epilepsy
Liver disease
Migraine (diagnosed by a doctor)
Cancer
Blood clots
Arthritis
Smoker
Other
We also need to know about any surgical history. Have you had any surgery in the past?
*
Yes
No
Please select any of the following that apply to you:
Appendicectomy
Heart Surgery
Bowel Surgery
Tonsillectomy
Gynaecological surgery
Weight loss surgery
Gallbladder surgery
Prostate surgery
Other
To help ensure safe treatment and good outcomes, it is important that a specialist is aware if you have had any previous cosmetic procedures. Have you previously had any of the following procedures? (select all that apply)
*
Non surgical cosmetic procedure(s), such as fillers, botox etc
Surgical cosmetic procedure(s)
Not sure/prefer not to say
No prior cosmetic procedures (surgical or non surgical)
From experience, we know that when patients are experiencing a high level of worry or stress about their appearance, they might be less satisfied with the results of a cosmetic procedure. To help ensure you get the best outcomes for both your physical and emotional wellbeing, we have a few more questions:
Are you very worried about your appearance in any way?
*
Yes
No
Do these concerns preoccupy you? That is, you think about them a lot and wish you could worry about them less?
*
Yes
No
Do these concerns often significantly interfere with your social life, work or ability to function in your role?
*
Yes
No
If you experience high levels of worry or stress that significantly impact your day to day functioning (whether related to your physical appearance or other issues), it is important to seek advice from an appropriately trained health professional such as a GP or psychologist.
*
Do you understand and accept this advice?
Yes
No
Have you had any allergies or bad reactions to any of the following medications?
Penicillins
Sulpha drugs
Antibiotics other than penicillin/sulpha drugs
Anti-inflammatories
Codeine
Morphine or morphine related medications
Other
I agree to provide an up-to-date list of all my medications to my specialist when I attend for my appointment
*
Yes
No
Do all the following apply to you? (please read carefully before confirming)
*
○ I am 18 years old or over, and currently in Australia.
○ This referral is for my own personal use only.
○ I understand that I am responsible for advising my specialist, and any other healthcare professional(s) I attend, of relevant information relating to my health and any changes in my health.
○ I understand that there may be a waiting list to see a specialist- if my condition gets worse in the interim I will seek medical attention.
○ I am aware there may be out of pocket costs for attending a specialist, which I will discuss with them.
○ I agree to the terms and conditions of use.
Yes, I confirm all the above
No
Thank you for completing this questionnaire- please click NEXT below to continue your booking
Please select a Video consultation or Phone Consultation
*
Video consultation
Please complete payment and then choose your appointment time.
The following times are available to book a consultation.
Please complete the following steps:
Purchase the consultation from the shopping cart
Select and confirm your telehealth consultation time
Click on the sms or email link 15 minutes prior to the start of your consultation time
The doctor will call you on the video link during your chosen time slot
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