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Dr. Elist Questionaire

 
First Name* Height
Last Name Weight
Date Of Birth    
       
 
Which procedure are you interested in?
Why? (Please explain, cite specifics)
What are your goals/expectations for this procedure?
Have you had any similar procedures before to address these concerns?
Are you happy with your results?
Why?
Have you researched other male enhancement procedure methods/doctors?
What stands out about Dr. Elist’s procedures to you?
Do you feel you are comfortable with all possible risks and benefits associated with the procedure? .
Are you comfortable speaking with one of our previous patients to better understand post-operative results
and expectations?
   

Medical Information
Are you allergic to any medications?
Are you currently taking any medications ?
Do you smoke? How Often?
Do you drink alcohol? How Often?
Do you take any recreational drugs? How Often?
Are you currently talking any aspirin, plavix, or any other blood thinning medication?
Do you have a history of high blood pressure, high blood sugar, asthma?

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