Plastic Surgery Questionnaire

Male      Female

Medical History:-

Please mention below the details about your medical history, including, but not limited to -
  1. If you ever had any problem with anaesthesia, please elaborate
  2. If you suffer from any chronic ailment, please furnish details
  3. If you are allergic to any medicine or drug, please mention details
  4. Details about any psychiatric treatment you have undergone in the past or presently undergoing
  5. Counselling sessions you take, if any



Yes      No

Social History:-


Yes      No



Yes      No

Obstetric History (For Female Patients)

Yes      No

Please upload your pictures here (Up to 10 Images)

We need well-lit pictures of your target areas taken from front, both sides and behind, preferably taken in front of a white background.
  1. For Body / breast procedures, you need to send unclothed pictures since the surgeons would like to assess the extent of excess skin / fat / descent of tissues.
  2. For Rhinoplasty procedure, we need pictures taken from front, both sides and head tilted behind.
  3. For Facelift, please send pictures without makeup. Please do not animate while taking pictures, i.e. no expressions on face.
  4. For Blepharoplasty/ brow lift, please send close up pictures of your eyes, showing the fine lines/ wrinkles (not too close)
You can take help from a friend/ your partner etc for taking pictures. In case you do not have anyone to take pictures, you can also take them standing in front of a mirror.
Disclaimer: Patient confidentiality is a top most priority at IndiCure. Your pictures and medical details would be completely safe with us and will only be shared on need basis with the treating surgeon(s).
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