The Center for Microsurgical Breast Reconstruction Are You a Candidate for Breast Reconstruction?  

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Make An Appointment
with Dr. Allen
Call Us Toll-Free
1-888-890-3437

South Carolina Office
125 Doughty Street
Suite 590
Charleston, SC 29403
Contact Us

New York Office
1776 Broadway
(at 57th), Suite 1200
New York, NY 10019
Contact Us

New Orleans Office
2525 Severn Ave.
4th Floor
Metairie, LA 70002
Contact Us

.................................

Make An Appointment
with Dr. Levine
Call Us Direct
212-245-8140
New York Office
1776 Broadway
(at 57th), Suite 1200
New York, NY 10019
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Candidate for Breast Reconstruction (Page 1 of 8 )

 
Your Contact Information (*Denotes Required Fields)
.................................................................................................................

First Name:*
Last Name:*
..............................................................................................

Address:*
City:*
State:*
Zip:*
Home Phone:*
Work Phone:
Cell Phone:
Fax:
   

 
"Getting to Know You!" (Please do not use quotes or apostrophes. Use hyphens)
......................................................................................................................
Your Height:* (example 5-5)
Your Weight:*

Social Security#:
Breast Size:*

Age:*
Date of Birth:*
   

 
Primary Insurance (*Denotes Required Fields)
...................................................................................................................
Person Responsible for Account:*

Insurance Company:*
Insurance Company Phone:*
Insurance Company Address:*
Insurance Company City:*
Insurance Company State:*
Insurance Company Zip:*

Subscriber Number:
Group Number:

Primary Care Doctor:		 Oncologist:

General Surgeon:		  
 


 
History of Present Breast Illness (*Denotes Required Fields)
...................................................................................................................

When Did the Breast Condition First Occur?:*

How was it Diagnosed?
Self Mammogram Physician Other

What side it the Tumor on?
Right Left Both N/A

What Type of Tumor
(if known)?
DCIS Invasive Ductal Lobular

What was the Size of the Tumor?

Number of Lymph Nodes Removed?
Number of Nodes Positive?
Date of Mastectomy?
Mastectomy Surgeon:
Date of Lumpectomy?
Lumpectomy Surgeon:
Date of Sentinel Lymph Node Procedure:

Describe any other breast surgery you have had so far
(including reconstruction if any)