|
Chief Complaint
• • •
|
|
|
Exam / Discussion: Check Box
|
|
|
Emailed Photos (Reviewed)?
|
Surgical Details Discussed?
|
|
Risks Benefits, and alternatives discussed?
|
|
|
Patients Questions Answered?
|
Pre-Op Survey
|
|
New Free Draw
|
New Free Draw
|
|
Pain Scale
/
|
|
|
Clinical Impression
|
|
|
Buttock Paucity
|
Others
|
|
Hip curves
|
others
|
|
Focal Adiposity
|
others
|
|
Breast
|
|
|
Hyposmastia-Ptosis
|
Symmetry
|
|
Capsular Contracture
|
Macromastia
|
|
Vagina
|
|
|
Labia Majora Right
• • •
|
others
|
|
Labia Majora Left
• • •
|
others
|
|
Labia Minora Right
• • •
|
Labia Minora Left
• • •
|
|
Symmetry
|
|
|
Clitoral Hood Right
• • •
|
Clitoral Hood Left
• • •
|
|
Hymen
|
|
|
Treatment Plan:
|
|
|
BAI
• • •
|
others
|
|
Hip Implants
|
SAL
• • •
|
|
Labiaplasty Majora
|
Labiaplasty Minora
|
|
Hoodectomy
|
Hymenoplasty
|
|
BAM
|
|
|
Mastopexy
|
Open Capsulectomy
|
|
Breast Reduction
|
|
|
Breast Reduction
|
|
|
Implants: Right
|
others
|
|
Implants: Left
|
others
|
