appointment request

Appointment details

You can save your appointment request and come back to it at any time. Scroll to the bottom of the form and click "save and complete later".

First Name *

Last Name *

DOB *

Email Address *Please double-check your email address or we may not be able to contact you!

I am located: *

in Australiaoutside Australia/ International

Mobile number *Australian mobile numbers only.

Mobile number (international) *International mobile phone numbers must include the country code

Preferred form of contact? *

MobileEmail

Postcode *

Country of residence *

Type of consultation *

In-person consultationVideo consultation / telehealth

Please note that video consultations/ telehealth appointments are reserved for patients who live interstate, or more than 1hr from Adelaide.

Are you available at short notice? *

Yes, always.No, never.Maybe, it would depend on the day/time.

We occasionally will have cancellations and appointments may become available. Our staff may contact you depending on your response.

Do you have Australian private insurance with hospital cover? *Please note that you do not need to have insurance to have surgery. You will still receive Medicare rebates where applicable if you don't have insurance.

Please select the operation you are interested in: *Please choose the most appropriate answer from this list. If you are interested in multiple procedures (eg. breast implant removal AND fat transfer or breast lift) let us know below.

What are your aesthetic goals from breast implant revision surgery? *

I want larger implants and a rounded upper poleI would prefer to have smaller implantsMy breasts have changed/dropped and I want this corrected (eg. with a breast lift)I am happy with my appearance but my implants need replacing (eg. due to rupture or age of implants)

Please select all that apply.

Can you tell us anything else?

When would you like to have surgery? *

Please tick here if you intend to apply for access to your superannuation (where applicable) for surgery?

Referral

Do you need a referral to see Dr Campbell-Lloyd?A referral should be provided by your regular GP or a referring specialist. Please note that a referral does not automatically entitle you to a Medicare rebate for your consultation.

Do you have a referral already? *

My referral has been/will be sent electronically to Dr Campbell-LloydI have a copy of my referral (paper or electronic)I have made an appt. with my GP to obtain a referral

Your Referral: *

Browse

Upload your referral here. Please ensure the referral is either a .jpg image or a .pdf document. If you have been advised above that you MUST have a referral, please note we will not allow appointment bookings until you have a referral and it has been received by us.

Your referral

Browse

If you have a referral, you can upload it here. Please ensure the referral is either a .jpg image or a .pdf document.

Cosmetic surgery requirements

"Cosmetic" surgery requirements

The procedure you have selected is considered to be Cosmetic.

Cosmetic procedures performed by Dr Campbell-Lloyd include: revision of previous explant surgery, cosmetic fat transfer for breast augmentation, cosmetic breast lift/mastopexy, or cosmetic breast implant revision surgery.

Please note: Medicare rebates are not applicable for consultations with Dr Campbell-Lloyd regarding purely cosmetic procedures. If you discuss multiple different procedures and this includes discussion of both cosmetic AND "medically necessary" procedures, then a Medicare rebate may apply. This can only be determined after your consultation.

AHPRA regulations now require that patients seeking purely cosmetic procedures complete additional steps, including:

a screening assessment for Body Dysmorphic Disorder, and
a separate consent for the use of clinical photography.

Cosmetic Procedure Screening (COPS) questionnaire

It is now an AHPRA requirement that all patients who are considering a cosmetic surgery procedure undergo routine screening for body dysmorphia.

Body Dysmorphic Disorder (BDD) is characterised by a preoccupation with one or more perceived defects or flaws in appearance which are unnoticeable to others.

We recognise that for many of our patients this is unlikely to be relevant, however we do ask that all patients complete this brief screening assessment honestly. It should only take 3 minutes of your time.

Please read the set of questions below and select the number that best describes the way that you feel about your breasts. Please read the various responses carefully to ensure you are selecting the answer that reflects how you feel because some of the answers are listed in a reverse order. Each question has a range of answers including answers that fall somewhere between specific responses.

1. How often do you deliberately check/look at your breasts? Not accidentally catch sight of them. Please include looking at your breasts in a mirror or other reflective surfaces like a shop window or looking at them directly or feeling/manipulating them with your hands. Choose one option, including those that fall between the definitions. *

2. How much do you feel your breasts are currently ugly, unattractive or ‘not right’? Choose one option, including those that fall between the definitions. *

3. How much do your breasts currently cause you distress? Choose one option, including those that fall between the definitions. *

4. How often do your breasts currently lead you to avoid situations or activities? Choose one option, including those that fall between the definitions. *

5. To what extent do your breasts currently preoccupy you? That is, you think about them a lot and it is hard to stop thinking about them? Choose one option, including those that fall between the definitions. *

6. If you have a partner, to what extent do your breasts currently have an effect on your relationship with an existing partner? (e.g. affectionate feelings, number of arguments, enjoying activities together). If you do not have a partner, to what extent do your breasts currently have an effect on dating or developing a relationship? Choose one option, including those that fall between the definitions. *

7. To what extent do your breasts currently interfere with your ability to work or study, or your role as a homemaker? (Please rate this even if you are not working or studying: we are interested in your ability to work or study.) Choose one option, including those that fall between the definitions. *

8. To what extent do your breasts currently interfere with your social life? (with other people, e.g. parties, pubs, clubs, outings, visits, home entertainment). Choose one option, including those that fall between the definitions. *

9. To what extent, do you feel your appearance is the most important aspect of who you are? Choose one option, including those that fall between the definitions. *

COPS score

Consent to the use of clinical images

Clinical images (which may include still images, or video) will be taken with your consent. These images will be stored securely as part of your medical record and will be used for reference during your treatment. *

You may have access to copies of the images stored in your medical file upon request. These images will be made available to you via our secure patient portal. *

Images may be used for education (of patients, healthcare professionals, staff and students), including but not limited to: during consultations, as part of lectures or presentations provided in person or online, and on Dr Campbell-Lloyd’s websites/social media. *

I consent to the use of my images for educational purposesI don't consent to the use of my images for educational purposes

Where images are used for educational purposes, recognisable features (face, tattoos, distinctive marks) may be digitally altered to prevent identification. Clinical images will never be edited in any other way to conceal, disguise, enhance or misrepresent the effects and outcomes of surgery. *

Where clinical images are used online, any identifying content within the metadata attached to an image file will be removed. *

At any time you may withdraw your consent for the publication of images online (including on our website or social media). We will ask that the withdrawal of consent be provided in writing, and this notification will be stored in your medical file. *

Further details and Submit

Previous surgery

If you have had any type of breast surgery in the past, please tick this box. You will be prompted to answer some more questions.

I have breast implants currently

Please tell us what you know about your current implants *Please provide any information you have about your implants. This may come from the implant card you received after your last surgery. If you don't have any information, that's ok! Just say "I don't know"

Have you had any other breast surgery? *

I have had previous implant revision proceduresI have had fat transfer to the breastsI have had previous explant surgery (ie. I do not have implants currently)I have had a breast lift or reduction (ie. I have a "lollipop" or "anchor" scar)I have had breast cancer surgeryI have had a breast reconstruction (any type)N/A

You can select multiple answers for this question.

Please tell us a little more about yourself:

Height *please ensure you have entered your height in metres, NOT in centimetres

Weight *

BMI calculation

Please note: We are not able to offer appointments to patients who are not at a safe surgical weight. For patients with an elevated BMI, we will recommend that you discuss your options for weight loss with your GP prior to requesting an appointment, in the interests of optimising your surgical outcomes. Thanks for understanding.

Do you currently smoke, vape or use any nicotine containing product ? *

Yes, dailySometimes, sociallyNo, never

Please be completely honest. Even occasional nicotine use can alter surgery outcomes. All patients MUST be nicotine free before we will allow surgery to be booked. This includes nicotine replacement therapy such as gum or lozenges.

Do you currently use cannabis or THC containing products? *

YesNo

Any cannabis/THC consumption MUST have ceased completely prior to booking surgery.

How did you hear about us? *

We strongly recommend that all patients check the online price guides on our website prior to an appointment. Please follow the link below.

Dr Campbell-Lloyd's surgery prices

Thanks for completing this form. Please click 'Submit' below. We will be in touch by email or phone to arrange a time that suits.

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