(770) 418-1234

3855 Pleasant Hill Road, #300 Duluth, GA

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(770) 817-9999

258 Pharr Rd NE #4, Atlanta, GA 30305

Online Consultation

Step 1: Completely Fill out the Form at the Bottom of this Page.

Step 2: Take the Photos

Have the six(6) required pre-operative photos taken of the area of the body you wish to improve. The photo set should include two(2) side views, two(2) three-quarter views, one(1) forward facing, and one(1) with the area of the body tilted back. Please view the examples below as reference.

In order for our doctor to adequately assess your candidacy, the photos must be taken in good lighting against a solid-colored background. There should be no shadows on the face. You can take the photos at home, using any camera with a zoom lens, by fully zooming in on the face. However, ordinary point-and-shoot cameras are not recommended because they distort the image too much for the resulting photos to be helpful. You may also have the pictures taken at any portrait studio.

Step 3: Submit the Forms, Photos, and Fee

Gather:

  • All completed forms
  • All requested photos
  • $200 consultation fee (You can pay this fee by either calling the office with your credit card information or mailing a check to the address below made out to Atlantic Center for Plastic and Cosmetic Surgery. This consultation fee will be applied to the surgery payment if you are a good candidate; if not, it will be returned)

e-mail the forms and photos to:

Or send them via U.S. mail, FedEx, or UPS to:

Atlantic Center for Plastic and Cosmetic Surgery

3855 Pleasant Hill Road, Suite 300

Duluth, Georgia 30096

Phone: (770) 418-1234

Step 4: Hear Back From Us

Our office will contact you via e-mail with the results of your screening.

Patient Name*
Mailing Address*
City*
State*
Zip*
Phone Number*
Date of Birth (MM/DD/YYYY)*
Email*

1. How did you hear about us?

2. Did another doctor refer you to us? If so, please list name.

3. How did you find our website?

4. What is your reason for seeing the doctor?*

5. If you are considering surgery, what are your realistic desires, i.e., what will/would it take for you to be satisfied with the outcome? Think about this and be honest.

Medical History

Do you or have you ever had any of the following?

Rheumatic Fever yesno

Heart Trouble yesno

Heart Murmurs yesno

Heart Palpitations yesno

Irregular Heart Beat yesno

Chest Pains yesno

Shortness of Breath yesno

Swelling of Ankles yesno

High Blood Pressure yesno

Herpes "Fever Blister" yesno

Chronic Lung Problems yesno

Diabetes yesno

Cancer yesno

Kidney Problems yesno

Eye Diseases yesno

Hepatitis yesno

Thyroid Problem yesno

Asthma yesno

Anemia yesno

Blood Disorders yesno

Skin Disorders yesno

Trouble with dryness, soreness, burning, itching, or excessive tearing of eyes yesno

Any other serious illness yesno

Have you ever had MRSA (Methicillin-resistant Staphylococcus aureus) yesno

6. Hospitalizations and/or previous surgery: (Please list with dates)

7. Allergies: Are you allergic to or have you ever had a reaction to any medication, drug or local anesthetic? Please list:

8. Medications: Are you now or have you ever taken any medications on a regular basis? (aspirin, birth control pills, vitamins included)? Please list:

9. Are you now or have you ever taken a prescription or over the counter medication for allergies, stuffiness, difficulty breathing, sinuses or other nasal problems? Please list:

Bleeding/Scarring/Anesthesia:

Do you or any member of your family have difficulty with prolonged bleeding when cut?

yesno

Do you or a member of your family bruise easily?
yesno

Do you have a problem with excessive scarring or have you ever formed a keloid after being cut?
yesno

Have you or any member of your family ever had a problem with anesthesia? yesno

Personal History

Is your general health good?

Have you ever had any psychiatric problems, a nervous breakdown or been under the care of a psychiatrist?**>
yesno

**If "Yes," please explain

Do you smoke? yesno

10. Date of last physical examination: (MM/DD/YYYY)

11. Do any diseases run in your family?

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Terms of Use
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Plastic Surgery Associations

Atlantic Center for Plastic and Cosmetic Surgery
3855 Pleasant Hill Rd
Suite 300
Duluth, Georgia 30096

258 Pharr Rd NE #4
Atlanta, GA 30305

Atlantic Center for Plastic & Cosmetic SurgeryAtlantic Center for Plastic & Cosmetic Surgery Atlantic Center for Plastic & Cosmetic Surgery Atlantic Center for Plastic & Cosmetic Surgery Atlantic Center for Plastic & Cosmetic Surgery

Duluth: (770) 418-1234
Fax: (770) 817-1110

Atlanta: (770) 817-9999

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© 2017 Plastic Surgeon R. Morgan Davoudi, M.D., F.A.C.S.| Atlanta Georgia | Atlantic Center for Plastic and Cosmetic Surgery
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