Pre-Visit Questionnaire

For the best consultation possible, please fill out as much relevant information in this pre-visit questionnaire as possible. We will try to respond quickly to your reply by email and/ or phone.

Name(Required)
Address(Required)
Gender(Required)
Date of Birth(Required)
Smoking
Which statement best describes your weight?

MEDICAL PROFILE

Do you have any medical conditions?
How would you describe your overall health?

PROCEDURES

PHOTOS

For the most accurate and complete virtual consultation experience, photos are necessary. Good lighting and photos that easily demonstrate the area(s). Please include photos of the desired procedure areas. Feel free to include "goal photos" as well if you would like.

Max. file size: 50 MB.
Drop files here to upload
Max. file size: 50 MB.
Drop files here to upload
Max. file size: 50 MB.
Drop files here to upload
Max. file size: 50 MB.
Drop files here to upload

BUDGET/ TIME FRAME

How soon do you plan to have surgery?

OTHER

This field is for validation purposes and should be left unchanged.

Get in Touch with Us

Ask us a question, request a private consultation, or submit a pre-visit questionnaire to Dr. Yates.

Get In touch

Long Contact Form

  • MM slash DD slash YYYY
  • * All indicated fields must be completed.
    Please include non-medical questions and correspondence only.
  • This field is for validation purposes and should be left unchanged.

Dr. York Yates Plastic Surgery

425 S 100 W,
Layton, UT 84041

801.525.8741

PRE-VISIT QUESTIONNAIRE

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