Top Plastic Surgeon
San Antonio, TX

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Patient Name *

Email *

Phone Number *

Current Address *

Marital Status *

What is your height? *

What is your current weight? *

Select Reason for Visit *

Arm LiftBreast AugmentationBreast LiftBreast ReductionBreast RevisionImplant RemovalBrow LiftBuccal Fat RemovalChemical PeelEyelid SurgeryEarlobe ReductionFace/Neck LiftFacial ImplantsForehead ReductionHair RestorationInjectables-neurotoxins/fillersLabiaplastyLip LiftLiposuctionLower Body LiftMicroneedlingMommy MakeoverRhinoplastyThigh LiftTummy TuckOther

History (fill out why you are here, what brought you to want this procedure, etc.) *

Primary Care Physician

Physician Name *

Phone Number *

How Did You Hear About Our Office? *

WebsiteFacebookInstagramSaw Your SignOther/Personal Referral

Emergency Contact

Emergency Contact Name *

Relationship *

Work Number *

Cell Phone *

Email *

Preferred Pharmacy Information

Pharmacy Name *

Address *

Phone *

Medical History

No significant past medical history

Medical History (Enter details below)

ArthritisAsthma or Lung DiseaseCancerDiabetesHeart ConditionsHigh CholesterolHypertensionHypotensionKidney DiseaseLumbagoLumbosacral root lesionsLupusPeripheral neuropathySeizures or EpilepsyScoliosisSpinal stenosisStrokeThyroid DiseaseOther

Enter details of medical history

Other Medical History Not Listed Above

Past Surgical History

Patient has no Previous Surgeries

Medical History (Enter details below)

Abdominal SurgeryAppendectomyArm LiftBladder Repair/SuspensionBody LiftBreast AugmentationBotoxBreast LiftBreast ReductionBrow LiftCardiac Surgery including StentsCesarean SectionCholecystectomyEyelid SurgeryFace LiftFacial FillersHernia RepairHysterectomyJoint ReplacementLiposuctionNeck LiftOophorectomyOrgan TransplantSpinal SurgerySplenectomyThigh LiftTonsillectomyTummy TuckOther

Please include the year you completed your past surgery. Please list the procedure(s) next to the year if multiple surgeries have been selected.

Allergies

I Have No Known Allergies

Allergies

PenicillinSulfaCephalosporinsQuinolonesIodineLatexDairyOther

What reactions did you have, if any?

Current Medications

Classes of Medications

Blood ThinnersChemotherapyDiabetes MedicationsPsychiatric MedicationsRheumatoid MedicationStatinsSteroidsNo Current MedicationsOther

Family History

No significant family history

Family History

DeceasedDiabetesHypertensionCancerHypotensionSkin DisordersEnvironmental AllergiesAsthmaHeart DiseaseGI ProblemsEmphysemaLipid DisordersAuto-Immune DiseaseCardiovascular DiseaseBronchitisArthritisHeadachesRheumatoid ArthritisStrokeGERDLung DiseaseObesityBlood DisorderPkd

Social History: Smoking

Have You Ever Been A Smoker? * YesNo

Are You Currently Smoking? * YesNo

If You Answered No, When Did You Quit?

If You Answered Yes, How Much Do You Smoke? 1-4 cigarettes per dayMore than 5 cigarettes per daySocial Smoking

Have you been offered Tobacco Cessation Counseling? YesNo

Do you vape? YesNo

Do You Use Any Form of Nicotine or Nicotine Replacement Therapy? If So, What Products?

GumInhalersLozengesNasal SpraySkin PatchOther

Social History: Alcohol, Drugs, Occupation, Hobbies

Do you drink alcohol? * YesNo

How Much Alcohol Do You Drink? Socially, On Occasion1-2 Drinks Per Day3-5 Drinks Per DayMore Than 5 Drinks Per Day

Do You Use Recreational Drugs? * YesNo

Drug Usage Details

CocaineHeroinCannabisEcstasyLSDBenzodiazepinesPCPAdderallBarbituratesAmphetaminesOpiatesKetamineMescalineASDF

What Are Your Hobbies / Athletic Activities? *

Occupation (Answering This Question Helps Guide The Surgical Recovery Discussion) *

Other: (Must Show Valid ID)

Signature*

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Face

Male

Non-Surgical

Breast

Body

Testimonials

New Image Plastic Surgery is my go-to for all things aesthetic! Whether it’s Botox, hair removal, or RF micro needling, Dr. Brostrom, Dr. Homas, and the team make every experience fantastic. I always recommend them to anyone on the lookout for exceptional aesthetic or plastic surgery services.

- Happy Patient

Dr. Dallas Homas is a very good surgeon! He is thorough, kind, and extremely knowledgeable. I’d recommend him to anyone. The facility is very nice and very clean two critical aspects that I look out for on my first visits. Of course, his office passes with flying colors! Even the staff is amazing!

- Happy Patient

Dr. Brostrom is an exceptional surgeon. I had abdominoplasty, lipo, and breast augmentation and she and her staff made the experience fun, welcoming, and absolutely worthwhile. I have noticed that my healing is much faster than what I have seen on average.

- Happy Patient

I’ve always been self-conscious about my facial features. I was so nervous to seek a consultation, I was sweating and my heart was pounding. The girl at the front desk was so nice and Dr. Homas was friendly, patient, and kind. He answered all of my questions and made it easy to understand. I felt safe and at ease.

- Happy Patient

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WE CAN’T WAIT TO MEET YOU!

BOOK A CONSULTATION

Whether you are looking for a subtle improvement or a big change, our staff will work with you to create a personalized treatment plan fit for your lifestyle! If you would like to get started on your journey to a new and improved you, please fill out the form below, or give us a call at (210) 640-6310

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20255 Stone Oak Pkwy San Antonio, TX 78258

(210) 640-6310

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5.0 stars - based on 19 reviews

Top Plastic Surgeon San Antonio, TX

Primary Care Physician

Emergency Contact

Preferred Pharmacy Information

Medical History

Past Surgical History

Allergies

Current Medications

Family History

Social History: Smoking

Social History: Alcohol, Drugs, Occupation, Hobbies

WE CAN’T WAIT TO MEET YOU!

BOOK A CONSULTATION

Top Plastic Surgeon
San Antonio, TX