(770) 418-1234

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3855 Pleasant Hill Rd #300 Duluth, GA 30096

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Internet Consultation

    Step 1: Take the Photos

    Have the six(6) required pre-operative photos taken as depicted below. 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 head tilted back.

    In order for Dr. Davoudi 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 2: Upload Photos

    Upload Photos:

    They will be emailed to us when you submit the form below, or you may also send them via U.S. mail, FedEx, or UPS to:
    Atlantic Center for Plastic and Cosmetic Surgery
    3855 Pleasant Hill Road, #300 Duluth, GA

    Step 3: Submit Consultation Fee

    $50 refundable 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. This consultation fee will be applied to the surgery payment if you are a good candidate; if not, it will be returned). We ask a 24 hour cancellation notice.

    Mailing Address: 3855 Pleasant Hill Road, #300 Duluth, GA

    Step 4: Completely Fill out and submit the form below.

    Patient Name*
    Mailing Address*
    Phone Number*
    Date of Birth (MM/DD/YYYY)*
    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. List in priority the things that bother you about your nose and what you would like corrected.
    6. If you have nasal breathing problems
    (if not, go to question #7)
    **Please answer (n/a) if not applicable
    a. Is your breathing problem primarily on one side or both?
    b. When does it bother you most?
    (season, time of day, with exercise, etc.)
    c. What can you do to improve your breathing?
    d. Please estimate the percentage you feel your breathing is decreased in each nostril.
    (Example: 100% = completely blocked, 50% = getting half the air you think you should, etc.)
    Left: Right:
    7. Have you had any previous nasal surgery? (If no, go to question #10)
    **Please answer(n/a) if not applicable
    If yes, now many?
    a. Was it to improve breathing, the appearance, or both?
    b. When was your last surgery performed?
    c. Who did your surgeries? (name of doctor and specialty)
    8. Do you know if any cartilage from inside your nose (the nasal septum) has been removed to correct a deviated septum or used as a graft to improve the shape of your nose?
    9. Has any cartilage or bone from other parts of your body (ribs, ears, skull, etc.) or any implants (artificial grafts) been used in your nose (Be specific)?
    10. Are you expecting insurance to pay for any part of your surgery? (They will usually pay only if you have significant nasal breathing problems or a traumatic deformity documented by x-ray, or verified by an emergency room visit.)
    If you are, what is the name of your insurance company?
    11. If you have 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
    12. Have you ever had MRSA (Methicillin-resistant Staphylococcus aureus)
    13. Hospitalizations and/or previous surgery(Please list with dates):
    14. Allergies: Are you allergic to or have you ever had a reaction to any medication, drug or local anesthetic? Please list:
    15. Medications: Are you now or have you ever taken any medications on a regular basis? (aspirin, birth control pills, vitamins included)? Please list:
    16. 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:
    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? YesNo
    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
    Previous cocaine use?** YesNo
    **If you have a history of cocaine use, you must provide clearance from an ENT doctor stating that you have no septal perforation, infection or damage to the internal lining of your nose.
    17. Date of last physical examination:
    18. Do any diseases run in your family?
    Terms of Use
    By checking this box you agree to the Terms of Use listed here: Communications through our website or via email are not encrypted and are not necessarily secure. Use of the internet or email is for your convenience only, and by using them, you assume the risk of unauthorized use. By checking this box you hereby agree to hold Atlantic Center for Plastic & Cosmetic Surgery, its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties.

    Step 5: Hear Back From Us

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

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        Atlantic Center for Plastic and Cosmetic Surgery
        Dr R. Morgan Davoudi
        3855 Pleasant Hill Rd #300 Duluth, GA 30096
        (770) 418-1234

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