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

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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
Contact Us





Candidate for Breast Reconstruction

Your Status
......................................................................................................................

Select Your Current Situation:

On Which Side was Your Mastectomy:

Have you had Previous Reconstruction:
Yes  No

If Yes, What Type:

About You (Please do not use quotes or apostrophes. Use hyphens)
......................................................................................................................

Your Height: (example 5-5)
Marital Status:
Married  Single Divorced 

Your Weight:

# of Children:

Occupation:
Bra Size:

Date of Birth:
...................................................................................................................

Do You Drink Alcohol?
Do You Smoke?
Yes No Yes    No   

If Yes, How Much:
If Yes, How Much:

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

First Name:*
Last Name:*
Email:*
Address:*
City:*
State:*
Zip:*
Home Phone:*
Work Phone:
Cell Phone:
Fax:

Do You Have Any Allergies/ Medications?
Please List Any Allergies:

Please List All Medication:
(including over the counter drugs, vitamins, & herbal supplements)



Medical History

Please Check All that Apply:
Heart Disease
Hypertension
Diabetes		 Kidney Disease
Asthma
Cancer
...................................................................................................................

Have You Had Past Surgeries?
Yes    No  
  If Yes, Please Explain:
 
...................................................................................................................

Any previous problems with general anesthesia?
Yes    No    
  If Yes, Please Explain:
 

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

Any previous complications from chemotherapy or radiation?
Yes    No     
  If Yes, Please Explain and Let Us Know When Your Last Treatment Was Completed:
 
...................................................................................................................

Is there a history of ovarian cancer in your family?
Yes    No     
  If Yes, Please Explain:




   

Miscellaneous
...................................................................................................................
How Would You Like Us to Initially Contact You?
Home Phone Work Phone Cell Phone E-Mail

Who is Your Insurance Carrier?

How Did You Find Us?

Please Specify if you've found us in a Chatroom or through Another Doctor:

Do You Have Any Comments?


 
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The Center for Microsurgical Breast Reconstruction
125 Doughty Street, Suite 590
Charleston, SC 29403

Toll Free: 888-890-DIEP (3437)
1-888-890-3437
Fax: (843) 727-3774		 The Center for Microsurgical Breast Reconstruction
New York City Office
1776 Broadway (at 57th), Suite 1200
New York, NY 10019

Phone: 212-245-8140
Fax: (212) 245-8157

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