Plastic Surgery Questionnaire

Male      Female

Yes      No

Medical History:-

Please mention all possible medical history information.
  1. Any problems with anesthesia?
  2. Any chronic illnesses?
  3. Any allergies to medications or drugs?
  4. Any psychiatric treatment or counselling?
  5. Any surgeries in the past?

  1. Prescription medications
  2. Over-the-counter medications
  3. Vitamins / Supplements / Herbal medications
  4. Psychiatric medications

Social History


Yes      No



Yes      No

Obstetric History (For Female Patients)

Yes      No

Pictures of Target Areas

Please upload your pictures here (Up to 10 Images)

We need clear and well-lit photos of the areas of your body that you would like to have surgery on. Please take the photos from the front, sides, and back, and preferably in front of a white background.
  1. For body or breast procedures, please send photos of your body without any clothing. This will help the surgeons assess the extent of excess skin, fat, or tissue descent.
  2. For rhinoplasty, please send photos of your nose from the front, sides, and with your head tilted back.
  3. For facelift, please send photos of your face without any makeup. Please also keep your face expressionless when taking the photos.
  4. For blepharoplasty or brow lift, please send close-up photos of your eyes. The photos should show the fine lines and wrinkles around your eyes, but please do not take the photos too close.
You can ask a friend, partner, or family member to help you take the photos. If you do not have anyone to help you, you can also take the photos yourself by 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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