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.

Make payable to: GEORGIA PLASTIC SURGERY SPECIALIST
Mailing Address: 3855 Pleasant Hill Road, #300 Duluth, GA

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

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. 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 YesNoNA
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:
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?	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?
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Step 5: Hear Back From Us

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