By completing this form, I acknowledge that I am interested in scheduling a consultation to discuss cosmetic, non-medically necessary surgical procedures. By completing this form, I acknowledge that I am interested in scheduling a consultation to discuss cosmetic, non-medically necessary surgical procedures. Yes

By completing this form, I acknowledge that I understand Boise Plastic Surgery will not be billing medical insurance, nor can they provide billing information beyond the Cosmetic Surgery, Non-Medically Necessary Surgery Quote. By completing this form, I acknowledge that I understand Boise Plastic Surgery will not be billing medical insurance, nor can they provide billing information beyond the Cosmetic Surgery, Non-Medically Necessary Surgery Quote. Yes

First Name

Last Name

Email Address

Phone Number

Date of Birth

When would you like to schedule your initial consultation appointment? We should have availability within the next few weeks.

If interested in scheduling cosmetic surgery, do you already have a timeline in mind? We may have availability within the next few months.

Do you think you’re interested in explant only surgery or explant with mastopexy (breast lift)? Of note, you can discuss these options with Dr. Cole during your consultation.

When were your breast implants placed? What type of implants do you have (silicone or saline)? What size are your implants? Do you know the manufacturer of your implants? Are they smooth or textured? If you don’t know these answers, it’s ok.

Are you having specific problems with your implants or experiencing any symptoms of Breast Implant Illness or BII?

Do you have any major medical issues or health conditions?

Have you had any breast imaging, mammogram, breast ultrasound, or MRI completed within the last year? Dr. Cole will need to review breast imaging done within one year of future surgery.

Do you live here within Boise or in nearby surrounding areas?

Are you traveling to us? If so, are you willing to travel for consultation first, and then plan for future surgery? Please keep in mind Dr. Cole would require you to stay here locally in Boise for at least 7 days after surgery to receive your immediate post-operative care, so traveling to us does add to the planning and finance of surgery. If you are hoping for consultation and surgery within one trip, our clinic nurse will need to coordinate all those details with you by phone and email.

Please share your best phone number and best time to reach you during the day, so our clinical staff can call you within the next couple weeks to discuss scheduling your consultation.