Plastic Surgery Consultation Note Template
The record of a first aesthetic or reconstructive consultation. It carries the patient’s goals in their own terms, the history that bears on suitability, the examination, what was offered, what was declined, and the risk discussion — which is the part that matters most if the outcome is ever questioned.
When it is used
At the initial consultation, and again at any consultation where the proposed procedure changes materially.
The template
AESTHETIC / RECONSTRUCTIVE CONSULTATION PRESENTING CONCERN Patient's stated goals (in their own words): Duration of concern: Prior consultations elsewhere: HISTORY Previous procedures (surgical and non-surgical, with dates): Previous revisions or complications: Relevant medical history: Medications and supplements: Allergies: Smoking / nicotine: Alcohol: BMI: Psychological history relevant to body image: EXAMINATION General: Site-specific findings: Measurements: Skin quality / laxity: Asymmetry noted and discussed: Photographs taken: yes / no — consent recorded: yes / no ASSESSMENT Suitability for requested procedure: Anatomical considerations: Expectation assessment: OPTIONS DISCUSSED Recommended: Alternatives discussed: Options declined by patient, with reason: Non-surgical alternatives discussed: No-treatment option discussed: yes / no RISKS AND CONSENT DISCUSSION General surgical risks discussed: Procedure-specific risks discussed: Likelihood of revision discussed: Recovery time and restrictions discussed: Written information provided: Patient questions and answers given: PLAN Agreed procedure: Pre-operative requirements: Cooling-off period: Next appointment: Outstanding items before booking:
Free to use and adapt. It is a structure, not clinical or legal advice — your records remain your professional responsibility.
Completed example
The same structure filled in, so you can see the level of detail it is built for. Details are illustrative and not from a real patient.
AESTHETIC CONSULTATION PRESENTING CONCERN Patient's stated goals: "I want them to look natural and in proportion — I don't want anyone to know." Concerned about volume loss following two pregnancies and breastfeeding. Four years' duration. No prior consultations. HISTORY Previous procedures: none. Relevant medical history: nil of note. No connective tissue disease. Medications: none. Allergies: none known. Non-smoker. Alcohol minimal. BMI 22. No history of body dysmorphic concerns elicited. EXAMINATION Bilateral breast ptosis, grade I. Volume loss in upper poles. Base width 12cm bilaterally. Nipple-to-fold 7cm right, 7.5cm left. Skin quality good, moderate laxity. Mild asymmetry noted (left marginally larger) — shown to patient and discussed. Photographs taken; written consent for clinical photography recorded separately. ASSESSMENT Suitable candidate for augmentation. Degree of ptosis does not require concurrent mastopexy, though this was discussed. Expectations realistic and consistent with achievable outcome. OPTIONS DISCUSSED Recommended: bilateral augmentation, anatomical implant, dual-plane. Alternatives discussed: augmentation with mastopexy; fat transfer. Declined by patient: mastopexy — prefers to avoid additional scars, accepts this limits correction of ptosis. No-treatment option discussed. RISKS AND CONSENT DISCUSSION Discussed: bleeding, infection, altered nipple sensation, capsular contracture, implant rupture, rippling, asymmetry persisting, scarring, need for future revision or replacement, anaesthetic risk, VTE. Explained that implants are not lifetime devices and that further surgery should be anticipated. Recovery and six-week restriction on upper body exercise explained. Written information pack provided. Patient asked about breastfeeding after surgery — explained that breastfeeding is usually possible with this approach. PLAN Agreed: bilateral augmentation as above. Pre-operative: routine bloods, implant sizing session. Two-week cooling-off period before booking. Review in two weeks to confirm and consent formally.
Documentation considerations
- Record the patient’s goals in their words before recording your assessment of them. The two are different pieces of evidence.
- Document options that were discussed and not chosen, with the reason. A record showing only the chosen procedure cannot demonstrate that alternatives were considered.
- The risk discussion should name the specific risks raised, not state that risks were discussed.
- Note expectations that were addressed as unrealistic, and what was said about them.
- Photography consent is separate from procedure consent. Record both.
Have this filled in for you
Patien listens to the encounter and returns the note in this structure. Templates are editable, so if your headings differ from these, change them once and every note follows.
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