Surgery Date Request

First Name *

Last Name *

Email Address *

Mobile *

What type of surgery has been recommended? ie eyelids (blepharoplasty, ptosis correction), facelift (rhytidectomy) etc *

Do you have a specific time frame in mind for your surgery? Please note whilst we endeavor to accommodate specific requests these are not always possible to meet *

Do you have any major travel plans, work or social committments in the next few months? Please detail *

I have checked with my health fund to see if I am covered for the hospital portion of this surgery (excluding cosmetic). *

YesNoThe exact procedure has not been confirmed yetNA - Procedure is cosmetic

I am aware that Dr Somia does not participate in any gap schemes *

YesNo

I understand there will be an out of pocket expense for the surgeon and anaesthetist fee *

Yes No

I have received an estimate/informed financial consent? If no, we will provide an estimate. *

YesNo

I understand a $1050 deposit is due 1 week after a date for surgery has been confirmed. *

YesNo

I understand a minimum of 2 consultations are required before a date for surgery can be confirmed and that one must be in person? *

YesNo

Have you had a 2nd consultation with Dr Somia? *

YesNoScheduled

If you have not had a 2nd consultation, would you prefer in person or virtual? Please note one of your consultations must be in person. *

VirtualIn person Bondi JunctionIn person Bella VistaNA - I have already had a 2nd consultation

Are you required to address any health concerns before scheduling surgery? Please detail *

Are you under the care of any specialists that need to give clearance for surgery? ie cardiologist, haematologist, psychologist etc. Please detail. *

If I use blood thinners, heart medications I am required to speak to my cardiologist to gain approval for surgery and cease these medications prior *

I understand the requirementsI do not understand the requirementsI do not take any blood thinners or heart medications

If I use an GLP-1 antagonist products ie Ozempic for weightloss or diabetes you will need to undertake a clear fluid diet 24 hours prior to the usual pre surgery fasting *

I understand the requirementsI do not understand the requirementsI do not take any GLP-1 antagonist products

If I use nicotine or vaping products I must cease these a minimum of 12 weeks before and after surgery to avoid wound healing issues *

I understand the requirementsI do not understand the requirementsI do not take any nicotine or vaping products

If I use a contraceptive pill I understand I need to cease this 2 weeks before to avoid clotting issues *

I understand the requirementsI do not understand the requirementsI do not use a contraceptive pill

I agree to update Dr Somia's office if my plans change or I no longer wish to proceed? This helps to keep our surgery list current and other patients to have surgery sooner.

YesNo

I understand that I must have a current GP referral for all consultations and surgery dates and that a referral from a specialist or GP who performs cosmetic services does not qualify? *

YesNo

Thank you for submitting a request for a surgery date.

Pre-surgery process

Following completion of this form we will contact you via email within one week with date options.

A $1050 non-refundable deposit is required within 1 week of accepting a date for surgery.

You will then be given access to our Surgery App which includes information on preparing for surgery including:

consent information
hospital forms
post surgery care
payment
education modules and FAQ's.

Important things to note:

Pre-surgery testing (bloods and ECG):

To identify any underlying health conditions that may need attention. These tests will be reviewed at a pre-operative consultation where you will finalise your procedure, have photos taken and any additional questions/concerns answered. In some cases specialist clearance is required from a cardiologist or haematologist. Consultation is $250.

Facial/eyelid surgery skin care protocol:

You will commence our pre-surgical skin care protocol 4-8 weeks before surgery (4 weeks eyelid 8 weeks facial surgery). Healthy skin can assist to optimise and maintain surgical outcomes, reduce recovery downtime and lower the risks of scarring/pigmentation following surgery. After undergoing surgery, the skin experiences a significant inflammatory period, decreasing the skin’s health and function. When the skin’s health is impaired, your surgical wounds will be slower to heal, may be more inflamed, or may form scar tissue more readily than healthier skin would. By preparing the skin with clinical skincare and treatments before and after surgery, you are more likely to heal faster and more optimally, while undergoing a more comfortable experience. More information will be provided once a date is confirmed.

Payment requirements:

The balance of Dr Somia's fee is due 4 weeks before surgery. Anaesthetist and hospital fees are due the week before surgery. In the event of cancellation within 4 weeks of surgery 30% of Dr Somia's fee is due.

We are here to help with any questions and look forward to assisting you.

Thank you for your request.

We will respond within one week with date availability.

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