Non-SurgicalMeeting Individualized Needs With World-Class Skin Care Treatments
The Gunter Center For Aesthetics and Cosmetic Surgery offers medically supervised skincare solutions and non-surgical procedures to treat your face and body. We specialize in skin restoration through a scientific approach, offering individualized planning with defined goals for all skin types. Our professional staff at the Gunter Center is highly trained, working under the direction of our physicians.
Our practice offers a variety of options to help you rejuvenate your skin, diminish signs of age and skin damage, and renew your appearance for a more youthful, healthy, and vibrant aesthetic. Our treatments include BOTOX® Cosmetic, injectable dermal fillers, intense pulsed light therapy, facials and chemical peels, professional skin care products, and much more. The investment you make now in good skin care will play a pivotal role in your personal aging process.
The following links will help you explore all the options you have here at the Gunter Center. Please contact us today for more information, or to schedule a consultation.
We offer financing through Care Credit. For more information, please click here .
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Gunter Center for Aesthetics & Cosmetic Surgery
8144 Walnut Hill Ln., Suite 170
Dallas, TX 75231
Phone: 214.380.0610
Fax: 214.369.2984
Internet Consultation Information Form
Patient Name* *
Mailing Address* *
City* *
State* *
Zip* *
Phone Number* *
Date of Birth (MM/DD/YYYY)* *
Email* *
1. How did you hear about us?
2. Did another doctor refer you to us? If so, please list name.
3. How did you find our website?
Search Engine
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4. What is your reason for seeing the doctor?* *
5. List in priority the things that bother you about your nose and what you would like corrected.
6. If you have nasal breathing problems (if not, go to question #7)
**Please answer (n/a) if not applicable
a. Is your breathing problem primarily on one side or both?
b. When does it bother you most? (season, time of day, with exercise, etc.)
c. What can you do to improve your breathing?
d. Please estimate the percentage you feel your breathing is decreased in each nostril. (Example: 100% = completely blocked, 50% = getting half the air you think you should, etc.)
Left
Right
7. Have you had any previous nasal surgery? (If no, go to question #10)**Please answer(n/a) if not applicable
If yes, now many?
a. Was it to improve breathing, the appearance, or both?
b. When was your last surgery performed?
c. Who did your surgeries? (name of doctor and specialty)
8. Do you know if any cartilage from inside your nose (the nasal septum) has been removed to correct a deviated septum or used as a graft to improve the shape of your nose?
9. Has any cartilage or bone from other parts of your body (ribs, ears, skull, etc.) or any implants (artificial grafts) been used in your nose (Be specific)?
10. Are you expecting insurance to pay for any part of your surgery? (They will usually pay only if you have significant nasal breathing problems or a traumatic deformity documented by x-ray, or verified by an emergency room visit.)
If you are, what is the name of your insurance company?
11. 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.
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
Have you ever had MRSA (Methicillin-resistant Staphylococcus aureus)
13. Hospitalizations and/or previous surgery: (Please list with dates)
14. Allergies: Are you allergic to or have you ever had a reaction to any medication, drug or local anesthetic? Please list:
15. Medications: Are you now or have you ever taken any medications on a regular basis? (aspirin, birth control pills, vitamins included)? Please list:
16. Are you now or have you ever taken a prescription or over the counter medication for allergies, stuffiness, difficulty breathing, sinuses or other nasal problems? Please list:
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
Personal History
Is your general health good?
Yes
No
Have you ever had any psychiatric problems, a nervous breakdown or been under the care of a psychiatrist?**
Yes
No
**If "Yes," please explain
Do you smoke?
Yes
No
Previous cocaine use?**
Yes
No
**If you have a history of cocaine use, you must provide clearance from an ENT doctor stating that you have no septal perforation, infection or damage to the internal lining of your nose.
17. Date of last physical examination: (MM/DD/YYYY)
18. Do any diseases run in your family?
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