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Plastic & Reconstructive Surgeon Template

Consultation Note

A professional Plastic & Reconstructive Surgeon template for healthcare professionals.
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Specialty

Plastic & Reconstructive Surgeon

Used

34 times

Type

Document

Last edited

4/14/2026

Created by

Rowan Chandler

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About this template

Need a clear and concise consultation note? This template is designed for plastic and reconstructive surgeons to document patient consultations efficiently. It provides a structured format to capture essential information, including the referring doctor, patient details, history of presenting illness, past medical and surgical history, medications, social history, physical exam findings, and the impression and plan. This template ensures all critical aspects of the consultation are addressed. With Heidi, this template can be quickly populated from your patient visit transcript, saving you valuable time on documentation. Start creating comprehensive and accurate consultation notes today.

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Dear Dr. Emily Carter, Thank you for your kind referral of Mrs. Evelyn Hayes. As you know, they are a very pleasant 62-year-old female who presents today with concerns regarding facial aging and a desire for facial rejuvenation. History of Presenting Illness Mrs. Hayes reports progressive changes in her facial appearance over the past several years, including deepening of nasolabial folds, sagging of the jowls, and the development of fine lines and wrinkles. She denies any acute onset of symptoms or associated pain. She is seeking consultation for potential cosmetic procedures to address these concerns. Past Medical History * Hypertension, well-controlled with medication. * Hypercholesterolemia, managed with diet and exercise. Past Surgical History * Appendectomy at age 10. Medications * Lisinopril 10mg daily. * Atorvastatin 20mg daily. Social History * Non-smoker. * Occasional alcohol consumption. * Lives with her husband. Physical Exam * Facial skin demonstrates moderate photoaging with fine lines and wrinkles. * Mild to moderate ptosis of the malar fat pads. * Deepening of nasolabial folds. * Mild jowling. * No significant asymmetry. Impression and Plan * Diagnosis: Facial aging. * Plan: Discussed various treatment options, including facelift, neck lift, and non-surgical interventions such as fillers and Botox. Patient is interested in a facelift and neck lift. Scheduled for pre-operative assessment and further discussion of surgical plan. Informed consent obtained.

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