Step 1 of 7 - Step 1 14% URLThis field is for validation purposes and should be left unchanged.Type of procedure*Type of procedureBreastNoseFaceEarName* Dr.MissMr.Mrs.Ms. Prefix First Middle Last Date of birth*The Patients date of birth Day Month Year Patient Address*Your residential address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Your mobile phone numberEmail*Please ensure this is correct, we may use it to contact you about your appointment. Medicare Number*Medicare Expiry Date*Medicare Reference Number*Are you a Private Health Fund Member?* Yes No Private Health Fund Name*Patient Name on Private Health Card*Private Health Membership Number*Private Health Reference Number* Next of kinThe name of the parent or guardian is required by Medicare. Dr.MissMr.Mrs.Ms. Prefix First Last Next of Kin RelationshipNext of Kin Phone NumberGP ReferralPlease upload your GP referral if you have it.Accepted file types: jpg, jpeg, gif, png, pdf, doc, docx, Max. file size: 10 MB. Referring Doctor*Please enter the name of your referring doctor.Local GPPlease enter the name of your local GP (if different to referring doctor).Address of Local GPPlease enter the address of your General Pratictioner. Describe your concerns about your breasts and what you goals of having surgery are*Describe your concerns about your face/eyes/neck and what you goals of having surgery are*Describe your concerns about your ears and what you goals of having surgery are*Do you have any concerns with the appearance of your nose that you are looking to discuss?* Yes No Describe your concernsHow many times a day would your nasal appearance bother you? Have you had other surgical cosmetic procedures before?* Yes No Describe the previous procedures you have had*On a scale of 1 to 10 please rate your current breast appearance.*On a scale of 1 to 10 please rate your current facial appearance.*On a scale of 1 to 10 please rate your nasal appearance.*On a scale of 1 to 10 please rate your current ear appearance.*Apart from your breasts are you satisfied with your general physical appearance? On the whole, I am satisfied with myself I think about unattractive parts of myself a lot I often get disappointed in myself I have a lot to be proud of My emotions can strongly bias my decisions People tell me that I look ok, but I don’t believe them I set higher standards for myself than most people I cope with stressful situations well I sometimes avoid situations because of my appearance I strongly dislike, and avoid, being in photos The opinion of others is very important to me Apart from your face are you satisfied with your general physical appearance? On the whole, I am satisfied with myself I think about unattractive parts of myself a lot I often get disappointed in myself I have a lot to be proud of My emotions can strongly bias my decisions People tell me that I look ok, but I don’t believe them I set higher standards for myself than most people I cope with stressful situations well I sometimes avoid situations because of my appearance I strongly dislike, and avoid, being in photos The opinion of others is very important to me Apart from your ears are you satisfied with your general physical appearance? On the whole, I am satisfied with myself I think about unattractive parts of myself a lot I often get disappointed in myself I have a lot to be proud of My emotions can strongly bias my decisions People tell me that I look ok, but I don’t believe them I set higher standards for myself than most people I cope with stressful situations well I sometimes avoid situations because of my appearance I strongly dislike, and avoid, being in photos The opinion of others is very important to me Apart from your nose are you satisfied with your general physical appearance? On the whole, I am satisfied with myself I think about unattractive parts of myself a lot I often get disappointed in myself I have a lot to be proud of My emotions can strongly bias my decisions People tell me that I look ok, but I don’t believe them I set higher standards for myself than most people I cope with stressful situations well I sometimes avoid situations because of my appearance I strongly dislike, and avoid, being in photos The opinion of others is very important to me I often compare aspects of my appearance to others Are you a perfectionist ? Yes No Are you a realist ?Please read through and select the motivations that apply to you considering breast surgery:* Look more attractive Look better in clothes/swimwear Correct changes after significant weight fluctuation Correct changes after childbirth or breastfeeding Reduce the signs of aging but still look like myself Feel more confident Feel happier Relationship reasons (e.g. Find a new partner, improve an existing relationship) Please read through and select the motivations that apply to you considering facial aesthetic surgery* Look more attractive Look younger Correct changes after significant weight fluctuation Reduce the signs of aging but still look like myself Feel more confident Feel happier Improve career prospects/job security Relationship reasons (e.g. Find a new partner, improve an existing relationship) Please read through and select the motivations that apply to you considering rhinoplasty surgery:* Look more attractive Look better in photos / videos / selfies Look more like I do in filtered / edited images Improve a specific feature that I feel conscious of Reduce the signs of aging but still look like myself Feel more confident Feel happier Work related reasons (e.g. Improve work performance, get a new job) Relationship reasons (e.g. Find a new partner, improve an existing relationship) Please read through and select the motivations that apply to you considering ear surgery:* Look more attractive Feel more confident Feel happier Relationship reasons (e.g. Find a new partner, improve an existing relationship) Have you been diagnosed or medicated in the past for Anxiety, Depression, Schizophrenia, an Eating disorder or Body Dysmorphism?* Yes No Please tell us more about your history of Anxiety, Depression, Schizophrenia, Eating Disorder, or Body Dysmorphism.* Are you on any weight loss drugs ( eg Ozempic etc)Are you currently on a weight loss journey ? Yes No Have you had previous non-surgical aesthetic treatments such as filler, Sculptra, Thermage, Radiesse ? Yes No Have you had other opinions so far about your facial aesthetic concerns? Yes No How many opinions ?If you have had more than one other opinion what were your concerns about the other options/surgeons ?Have you seen the work of Dr Greensmith Yes No Where On his Instagram On his website Have you had other opinions so far about your ear concerns? Yes No How many opinions ?*Have you had other opinions so far about your nose concerns? Yes No How many opinions ?*Have you had other opinions so far about your breast concerns? Yes No How many opinions ?*If you have had more than one other opinion what were your concerns about the other options/surgeons ?*How did you hear about Dr Greensmith?* Word of mouth Aesthetic surgery forums Have seen work on his website Have seen his Instagram
