Plastic Surgery Hawaii Evaluation Form

Use the form below to receive an initial opinion from Dr. Pasquale at no charge. This is for your educational purposes only, and can not be considered a true medical opinion without a proper examination in person. Dr. Pasquale may be able to give you some ideas and insight on how to obtain your goals in appearance as it relates to cosmetic and plastic surgery.

Patient Name:

Email Address:

Phone Number:

1. List the things you would like to change.

2. Have you had any previous cosmetic surgery?

a. What was the reason for your surgery?

b. When was your last surgery performed?

c. Who performed your surgeries?
(Name of Doctor & Specialty)

3. If you have not had another 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.

677 Ala Moana Blvd. Suite 404 • Honolulu Hawaii 96813 • Phone: 808-737-0205 • Privacy Notice
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