DR ARNOLD DOUGLASPlastic & Reconstructive Surgeon

Periorbital Rejuvenation ·Precision Skin Health ·Craniofacial Reconstruction ·The Skin as a System™ ·Aesthetic Breast Surgery ·Founder of SKNCODE™ ·Cape Town, South Africa ·Periorbital Rejuvenation ·Precision Skin Health ·Craniofacial Reconstruction ·The Skin as a System™ ·Aesthetic Breast Surgery ·Founder of SKNCODE™ ·Cape Town, South Africa ·Periorbital Rejuvenation ·Precision Skin Health ·Craniofacial Reconstruction ·The Skin as a System™ ·Aesthetic Breast Surgery ·Founder of SKNCODE™ ·Cape Town, South Africa ·Periorbital Rejuvenation ·Precision Skin Health ·Craniofacial Reconstruction ·The Skin as a System™ ·Aesthetic Breast Surgery ·Founder of SKNCODE™ ·Cape Town, South Africa ·Periorbital Rejuvenation ·Precision Skin Health ·Craniofacial Reconstruction ·The Skin as a System™ ·Aesthetic Breast Surgery ·Founder of SKNCODE™ ·Cape Town, South Africa ·Periorbital Rejuvenation ·Precision Skin Health ·Craniofacial Reconstruction ·The Skin as a System™ ·Aesthetic Breast Surgery ·Founder of SKNCODE™ ·Cape Town, South Africa ·Periorbital Rejuvenation ·Precision Skin Health ·Craniofacial Reconstruction ·The Skin as a System™ ·Aesthetic Breast Surgery ·Founder of SKNCODE™ ·Cape Town, South Africa ·Periorbital Rejuvenation ·Precision Skin Health ·Craniofacial Reconstruction ·The Skin as a System™ ·Aesthetic Breast Surgery ·Founder of SKNCODE™ ·Cape Town, South Africa ·

Reconstructive Patients

Patient Intake Form

Complete this confidential form before your consultation — at home, or in the waiting room when you arrive. It gives Dr Douglas a head start on your care.

Your Details

Full Name *

Email Address *

Phone Number

Date of Birth *

Gender *

Your Health

Just enough for a head start — Dr Douglas will go through everything with you in person.

Reason for Your Consultation *

Previous Medical History

Previous Surgical History

Current Chronic Medication

Allergies

Supplements & Herbal Products

Smoking

Alcohol Use

Anything Else We Should Know?

Consent

I consent to Dr Arnold Douglas and his practice collecting, storing and processing my personal and medical information for the purpose of my consultation and treatment, in accordance with the Protection of Personal Information Act (POPIA). I understand my information is kept confidential and will not be shared with third parties except as required for my care or by law. *