Registration Form – Dr. Anna Todd *Fields marked with an asterisk are mandatory and will need to be filled in for a successful submission. **Liposuction will only be performed in conjunction with another procedure. **In accordance with Body Mass Index (click here to calculate your BMI) protocols we have included the maximum BMI for each procedure: Breast Procedures, Mommy Makeover, Brachioplasty, Liposuction, Abdominoplasty – BMI 30. Teenage Breast Reduction – BMI 25 Registration form Dr. Anna Todd Procedure(s) of Interest * Breast Augmentation Breast Lift (mastopexy) Breast Reduction Corrective Breast Surgery Fat Grafting Mommy Makeover Liposuction – Abdomen (in conjunction with another procedure only) Liposuction – Thighs (in conjunction with another procedure only) Liposuction – Flanks (in conjunction with another procedure only) Inverted Nipples Abdominoplasty Hand surgery Blepharoplasty Breast reconstruction Top surgery (gender affirming) Otoplasty Skin cancer Lipoma Choose your Mommy Makeover: Abdominoplasty + * Breast AugmentationBreast Lift (mastopexy)Breast ReductionCorrective Breast Surgery Please provide more details for your Breast Corrective Surgery * Full Name * Full Name First First Last Last Address * City * Province * Postal Code * Phone * Birthdate * Email * Emergency Contact Name * Relationship to you? * Contact phone number * Healthcare number? * Province of issuance? * Full name on card? * Do you authorize Banff Plastic Surgery to disclose the information enclosed with anyone besides yourself? * Yes No If yes, who & what relationship are they to you? * Full name of family physician * Full name of family physician First First Last Last Physician’s office address in full * We normally like to communicate with your family physician about your care. Do you provide us permission to do so? * Yes No How did you hear about us? * A family member told me about Dr. Hall-FindlayA friend told me about Dr. Hall-FindlayBanff Plastic Surgery websiteFacebookI heard Dr. Hall-Findlay speakI’m a previous patientInstagrammiraDry websiteMy doctorOther websiteSearch engineYouTubeOccupation Occupation * Height * Weight * Have you lost weight? * Yes No If so, how much? * Bra size (for breast surgery only) Have you had breast cancer? * Yes No Is there a history of breast cancer in your family? * Yes No Have you ever had a heart attack or heart trouble? * Yes No If so, what type of testing was done? * Do you have a stent? * Yes No Have you ever had a stroke? * Yes No Do you ever have difficulty with your breathing? * Yes No Do you smoke nicotine products? * Yes No What previous surgeries have you had? (Please provide the year of each procedure). * Do you have any allergies to medications, food, or environmental? * Please list any medications, including pills, inhalers, patches, herbal preparations, or birth control you are currently taking (prescription or over the counter) * Do you have children? * Yes No Did you breastfeed? * Yes No Have you ever had a mammogram? * Yes No If so, when was the last one (month/year) * Have you been in any major accidents? * Is there anything that I should know about your medical/obstetrical/surgical or psychiatric history? * Yes No * Have you been fully vaccinated for COVID 19? * Yes No Any other comments? Captcha Submit If you are human, leave this field blank.
