Patient Information
Have you already scheduled a date for surgery with Didi? *
Yes No
If yes, when
If no, please don't continue filling out this form. If you haven't already been assigned a date by Didi please email her at trlwd@aol.com to schedule.
Tobacco User: *
NON Smoker Smoker
Date of Birth *
First Name: *
Last Name: *
Age: *
Occupation:
Email Address : *
Phone: *
FAX
Address: *
City: *
State: *
Zip Code: *
What is the date of your scheduled surgery? *
*Must have a date scheduled before sending this form
What kind of surgery or surgeries would you like to have done?
How did you hear about Dr. Lev?
Personal Data
General health condition: *
Good
Fair
Poor
Weight: *
Height: *
Previous Surgery (Please list):
Have you had any significant complications from any of these operations? *
Yes No
What is your daily consumption of Coffee or Tea: *
What is your daily consumption of Tobacco: *
What is your daily consumption of Alcohol: *
Please list all medications you are now taking: *
Are you allergic to any medicines? (If yes, please list): *
Do you tend to work and play well with others?(you may be with other people recovering at the recovery retreat) *
Have you ever had a bad reaction to being put to sleep for surgery? *
Yes No
Have you ever had a bad reaction to local anesthesia? *
Yes No
Are you allergic to adhesive tape? *
Yes No
Do you have high blood pressure? *
Yes No
Do you have diabetes? *
Yes No
Do you have cardiac problems? *
Yes No
Do you have or have you ever had any significant emotional problems? *
Do you take anti-depression medications? *
Yes No
Do you have or have you ever had Dry eyes? *
Yes No
How many children do you have? *
Age of your younger children: *
Have you been on a strict diet in the last 3 months or taking diet pills? (please list) *
When did you take your last aspirin or any medicine containing aspirin, anti-inflammatory medicines or vitamin E (stop taking these medications at least 2 weeks before surgery)? *
Please share anything else you feel the doctor should know about your general health. *
Smokers Must Read:
Dr. Lev will not accept patients who smoke. He says that, generally speaking, smokers have poor blood circulation, which is extremely dangerous in terms of the healing process. If you are a smoker, you must completely cease from smoking at least four weeks before surgery or else you are at high risk for getting a necrosis.
According to Dr. Lev, a necrosis occurs when, due to poor blood circulation, oxygen is not adequately provided to the traumatized areas post-surgery. This often causes the affected of skin to literally die, turn black and fall off. I know this is very graphic, but many smokers do not take this seriously, and it is a very serious situation. After about one year, the skin regenerates itself, leaving an unsightly scar.
In the past, there have been patients who were smokers who told Dr. Lev they were not. Needless to say, Dr. Lev believes whatever his patients tell him. Therefore, a misrepresentation regarding smoking puts the patient at great risk. If something should happen to the patient as a result of that misrepresentation, it is extremely disturbing to Dr. Lev.
Your safety and excellent results are of paramount importance to him. Shouldn’t it be of paramount importance to you, too? It really isn’t worth putting yourself through an unnecessary risk for the sake of plastic surgery, is it? So, smokers beware and understand that you've been forewarned!
If you have read and understand the notice to smokers' risks *
Click here
Will you agree to stop smoking at least one month prior to your surgery? *
Yes No
Enter the code as it is shown: *
