(770) 418-1234

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Online Consultation
3855 Pleasant Hill Rd #300 Duluth, GA 30096

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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


  • All completed forms
  • All requested photos
  • If you live in the state of Georgia, we are requesting you be seen in person and there is a $100 consultation fee (non refundable – but can be applied toward procedure). No fee for out of state quotes.

e-mail the forms and photos to: tresh@drdavoudi.com

Step 4: Hear Back From Us

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

    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. 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:


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


    Do you or a member of your family bruise easily?

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

    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?**>

    **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?

    Please enter the verification code:

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    Check here to agree: (form will not be sent unless checked)

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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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