Consultation For Breast Surgery Questionnaire

This form has been provided by:

http://boobjobsupportforum.forumotion.co.uk Date: _____ / _____ / 20____ Clinic: ________________________________ Surgeon: ________________________________ Fill this in after you’ve been seated in the waiting room, but before you see your surgeon/PCC Was the reception/front of house staff helpful and respectful? Was I seen on time? [ ] Yes [ ] No Was I offered a drink? [ ] Yes [ ] No Was the clinic tidy? [ ] Yes [ ] No

[ ] Yes [ ] No

The PCC (patient care co-ordinator) Name of your PCC: _________________________________ Questions to ask: What implants does your clinic supply? [BEWARE of PIP implants, they have a bad reputation for rupture, and some have been pulled from the MHRA list – if PIP implants are mentioned, ask if they offer alternatives.]

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How much will my surgery cost me in total, including implants, theatre hire fees, anaesthetist’s charges etc? £_________ Am I entitled to any discounts? [ ] Yes [ ] No Are you willing to negotiate on the price? [ ] Yes [ ] No What is your policy on revisions should I be unhappy with the results, or have a complication? If I am unhappy with my size, will I be able to get a re-op for free? [ ] Yes [ ] No Am I covered for the following complications, and for how many years after surgery: Capsular contraction

Covered for free? How many years:

[ ] Yes [ ] No

Rupture Covered for free? [ ] Yes [ ] No How many years? Pocket revision for bottoming out Covered for free? [ ] Yes [ ] No How many years Severe scarring Covered for free? [ ] Yes [ ] No How many years? Symmastia Covered for free? [ ] Yes [ ] No How many years? Rippling/Creasing Covered for free? [ ] Yes [ ] No How many years? Infection/Haematoma Covered for free? [ ] Yes [ ] No How many years Will I have to pay for my aftercare, e.g. bandaging, steri-strips, lotions etc? [ ] Yes [ ] No If yes, how much? £________ Are all post op visits free, or will I need to pay to see my surgeon for aftercare? [ ] Yes [ ] No Will I see a nurse or my surgeon after my operation? Nurse / Surgeon If my surgeon moves clinic, how does this affect my aftercare? Will I still be able to have my full aftercare package? What type of warranty will I receive with my implants? Is there a doctor/nurse on call 24 hours a day in case there are problems a ew days/weeks after my surgery? [ ] Yes [ ] No Will I be able to contact my surgeon directly should there be a problem? [ ] Yes [ ] No Will I be provided with a compression bra after my surgery? [ ] Yes [ ] No If no, what bra shall I purchase? Does smoking affect the healing process, and if so, how far in advance of surgery should I quit? ____________________________ Fill this in after you’ve seen your PCC.

Did you feel she knew about the procedure? [ ] Yes [ ] No Did you feel pressurised into booking your date there and then? [ ] Yes [ ] No Did she offer me a copy of the clinic’s terms and conditions of surgery? [ ] Yes [ ] No The Surgeon Questions to ask: Which implants will be best for me, round or anatomical? Round / Anatomical [delete as applicable] Why? Which placements are you capable of performing? What placements are suitable for me? Overs / Partial Unders / Full Unders Which placement would you recommend in my case? ________________________ Why? __________________________________________________________ Which incision would you recommend for me? Crease / Armpit / Nipple What sized implant would you recommend for me? ________cc Will I have a GA (general anaesthetic) or twilight sedation? GA / Twilight Do you use dissolvable stitches? [ ] Yes [ ] No Do you use sizers during surgery? [ ] Yes [ ] No What sized surgery bra should I wear after surgery? ________________________ Shall I take arnica before surgery? [ ] Yes [ ] No Will I need a lift, and if so, which breast lift is right for me? [ ] Yes [ ] No Can I breastfeed after surgery? [ ] Yes [ ] No Will my breasts sag quicker with implants? [ ] Yes [ ] No Will I lose feeling in my nipples/breast tissue after surgery, and can it be permanent? [ ] Yes [ ] No I want to lose weight. Shall I wait until I’m at my ideal weight before having surgery? [ ] Yes [ ] No

I want children. How will this affect my breasts? ____________________________________________________________ How long will my surgery last? [ ] >30mins [ ] 30mins to 1hr [ ] 1-2hrs [ ] 2hrs + How long shall I take off work? _______ days When can I exercise again? _______ days / months When can I drive? _______ days When can I have a shower after surgery? ______ days Can I wear makeup on my surgery day? [ ] Yes [ ] No Fill these in after you’ve seen your PS Was he qualified adequately for his job? [ ] Yes [ ] No Was he a member of any specialist organisations or bodies i.e. BAAPS? [ ] Yes [ ] No How many augmentations does he perform each year? _______ Did he have before and after photos available for viewing? [ ] Yes [ ] No Did you feel at all rushed or passed aside? [ ] Yes [ ] No Did you trust his judgement and his opinions on surgery? [ ] Yes [ ] No

Thinking about your consultation, what overall impression did you get?