An online consultation is available for those patients who live outside of the Los Angeles area or who are otherwise unable to come to our office in Beverly Hills.

The online consultation consists of several steps that are designed to determine the very best options available to achieve your desired goals including a thorough questionnaire and submission of pictures.

Once the information is received, Dr. Diaz will carefully review the details and will personally contact you.

You will be given the same superior level of attention and care that you would experience if you came to the office.

All questions must be answered before the form can be submitted.

* Mandatory Fields

Patient Name: *


Mailing Address: *


City: *


State: *


Zip Code *


Area Code and Phone Number: *


Date of Birth: *
(MM/DD/YYYY)


Email Address: *

1. How did you hear about us?


2. How did you find our website?
Choose one... Search Engine Advertisement A friend Unknown

3. What is your reason for seeing the doctor?


4. List in priority the things that bother you and that you would like corrected.


5. If you have surgery, what are your realistic desires, i.e., what will/would it take for you to be satisfied with the outcome? Think about this and be honest.


6. Feel free to send us photographs from any magazines, or other source, of the type of result you like.

Medical History:
Do you or have you ever had any of the following?

Rheumatic Fever	Yes No
Heart Trouble	Yes No
Heart Murmurs	Yes No
Heart Palpitations	Yes No
Irregular Heart Beat	Yes No
Chest Pains	Yes No
Shortness of Breath	Yes No
Swelling of Ankles	Yes No
High Blood Pressure	Yes No
Herpes "Fever Blister"	Yes No
Chronic Lung Problems	Yes No
Diabetes	Yes No
Cancer	Yes No
Kidney Problems	Yes No
Eye Diseases	Yes No
Hepatitis	Yes No
Thyroid Problem	Yes No
Asthma	Yes No
Anemia	Yes No
Blood Disorders	Yes No
Skin Disorders	Yes No
Trouble with dryness, soreness, burning, itching, or excessive tearing of eyes	Yes No
Any other serious illness	Yes No

Bleeding/Scarring/Anesthesia:
Do you or any member of your family have difficulty with prolonged bleeding when cut?
Yes No

Do you or a member of your family bruise easily?
Yes No

Do you have a problem with excessive scarring or have you ever formed a keloid after being cut?
Yes No

Have you or any member of your family ever had a problem with anesthesia?
Yes No

7. If you are considering breast surgery, have you had a mammogram? If so, when was your last mammogram and what was the result?

8. Hospitalizations and/or previous surgery:
Please list with dates:

9. Medications: Are you now or have you ever taken any medications on a regular basis (aspirin, birth control pills, vitamins included)? Please list:

10. Allergies: Are you allergic to or have you ever had a reaction to any medication, drug or local anesthetic? Please list:

11. Do any diseases run in your family? If you are considering breast surgery, let us know if there is anyone in your family who has had breast cancer.

Personal History:
Have you ever had psychiatric problems, a nervous breakdown or been under the care of a psychiatrist?**
Yes No

**If "Yes," please explain:



Do any diseases run in your family?


Do you smoke?
Yes No

Do you drink alcohol? If so, approximately how many drinks do you have a week?

Previous drug use?
Yes No

?