M.K. Ambe M.D. Newport Beach, California, 949.759.5539

Out of Town Patients

We are glad to offer e-consultations for our prospective out of town and out of state patients who can not simply come in to our office for a complimentary consultation.  

Dr. Ambe has developed an advanced, in depth protocol for patients that choose come to us from out of town and state for their aesthetic surgical needs. In order to appropriately address patient needs and determine whether he or she is a candidate for cosmetic surgery we must first gather some information . Once this e-consult form has been completed there is a place to attach photos of yourself for Dr. Ambe to review (you will find instructions on how to take your photos and attach them at the end of the econsult form).

Places to Stay


The Resort at Pelican Hill
Patti Perez | Leisure Sales Manager
22701 Pelican Hill Road South | Newport Coast, CA | 92657
Phone: 949.467.5911 | Fax: 949.467.6876 | Cell: 858.204.7885
Email: pperez@pelicanhill.com


The Balboa Bay Club Resort
Darragh Flood | Sales Manager
1221 West Coast Highway | Newport Beach, CA 92663
Phone (Direct): 949-630-4223 | Fax: 949-630-4315
Email: dflood@balboabayclub.com


Marriott Newport Beach Hotel and Spa
Michael Francisco
900 Newport Center Drive | Newport Beach, CA  92660
Phone: 949-640-4000 | Toll Free: 866-440-3375


Hyatt Regency Newport Beach
Dominique Davidson | Sales Manager, Business and Leisure Travel
1107 Jamboree Road | Newport Beach, CA 92660
Phone: 949.729.6069 | 4949.759.3253
Email: dominique.davidson@hyatt.com



The Island Hotel
Kristine Flynn
690 Newport Center Drive | Newport Beach, CA 92660
Phone: 866-554-4620
Email: fflynn@theislandhotel.com



Restaurants to Eat


This section will be updated soon.



E-Consult Form


Please fill out the information below to obtain an e-consultation with Dr. Ambe.

Purpose of consultation:  
NAME: AGE:
BIRTHDATE: HOME ADDRESS:
CITY:STATE:
ZIP: HOME PHONE:
SEX: MARITAL STATUS: 
CELL# : HEIGHT:
WEIGHT:EMAIL ADDRESS: 
OCCUPATION : WORK PHONE: 
WHO REFERRED YOU TO OUR OFFICE   

PERSONAL HISTORY/ILLNESS

HAVE YOU EVER HAD 
HIGH BLOOD PRESSURE:Yes  No
LOW BLOOD PRESSURE :Yes  No
HEART DISEASE:Yes  No
HEART ATTACKS:Yes  No
BLOOD CLOTS:Yes  No
PHLEBITIS:Yes  No
STROKE:Yes  No
DIABETES:Yes  No
GOUT :Yes  No
SINUS TROUBLE :Yes  No
ASTHMA :Yes  No
EMPHYSEMA:Yes  No
BRONCHITIS:Yes  No
STOMACH ULCER:Yes  No
COLITIS:Yes  No
ANEMIA:Yes  No
KIDNEY STONES:Yes  No
CIRRHOSIS:Yes  No
HEPATITIS:Yes  No
TUBERCULOSIS:Yes  No
CANCER:Yes  No
THYROID DISEASE:Yes  No
EPILEPSY / SEIZURES:Yes  No
NERVOUS BREAKDOWN:Yes  No
VENEREAL DISEASE:Yes  No
POSITIVE HIV TESTING:Yes  No
ANY OTHER DISEASES-LIST:
ANY FAMILY HISTORY OF THE ABOVE? IF SO, PLEASE LIST:
PLEASE LIST ANY PRIOR SURGERIES:
LIST ANY MEDICATIONS YOU ARE TAKING INCLUDING BIRTH CONTROL, HERBS,VITAMINS, ETC.
LIST ANY CURRENT OR PAST RECREATIONAL DRUG USE:
HAVE YOU EVER BEEN TREATED FOR CHEMICAL DEPENDENCY?Yes  No
ARE YOU ALLERGIC TO THE FOLLOWING?   
PENICILLIN:Yes  No
SULFA:Yes  No
ASPIRIN :Yes  No
CODEINE:Yes  No
LIST ANY OTHER MEDICATIONS YOU ARE ALLERGIC TO:
DO YOU SMOKE? :Yes  No
IF YES, PACKS PER DAY:
QUIT SMOKING? :Yes  No
YEARS SMOKED?:
DO YOU DRINK ALCOHOLIC BEVERAGES?NEVER
RARELY
SOCIALLY
MODERATE
COUGH:Yes  No
EXCESSIVE SPUTUM:Yes  No
SHORTNESS OF BREATH:Yes  No
CHEST PAIN OR ANGINA:Yes  No
PALPATIONS:Yes  No
NAUSEA OR VOMITING: Yes  No
DIARRHEAS:Yes  No
CHRONIC HEADACHES:Yes  No
DIZZINESS:Yes  No
DO YOU BRUISE EASILY:Yes  No
DO YOU BLEED EASILY:Yes  No
HAVE YOU EVER HAD ANY PROBLEMS WITH PREVIOUS LOCAL OR GENERAL ANESTHETIC AGENTS? IF YES, PLEASE GIVE DETAILS
Please take photos in manner similar to the ones in our photo gallery. Whether it's facial or body please take front view and a side view so that Dr. Ambe may properly asses your needs. Please also enter a brief description of what bothers you exactly.
 

Front View

Right View

Left View

By clicking the box, you verify that you are 18 years or older. You may only upload images to our econsult form if you are over 18 years of age.