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
Restaurants to Eat
E-Consult Form

Places to Stay

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.