Virtual Consultation Form First Name* Last Name* Age GenderPlease Select OneMaleFemale Weight Height Phone* Email* How would you like us to respond?PhoneEmail Areas of Concern & Procedures You are Considering: When are you hoping to have this procedure done?*Please Select OneASAP3 Months6 Months + Is there an event that is motivating you? Have you had cosmetic surgery before?YesNo If yes, please indicate surgical procedures How long have you been thinking about cosmetic surgery?*Please Select OneLess than 3 monthsAbout 6 months1-2 YearsMore than 2 years On a scale of 1-10, how important is this surgery to you?* What are your expectations & concerns of this procedure?* Where are you in your decision-making process?*Please Select OneI'm just starting to think about itI've started researching procedures and doctors in my areaI've done my research, but I have more questionsI've decided I want the procedure, I'm just waiting for a good timeI'm ready to book my procedure now PLEASE USE THE UPLOAD BUTTON BELOW TO UPLOAD PHOTOS TO SEND TO US To make the most of your virtual consultation, do your best to submit your photographs in the following format. This will allow our doctors to make the most comprehensive assessment. 1. Use a solid background. 2. Take one frontal photo with the face or body centered and looking straight. 3. Take at least one, preferably two profile photos File formats accepted: gif | png | jpg | jpegFile size limit: 3mb Photo 1* Photo 2 Photo 3 Photo 4 By checking this box you agree to the Terms of Use listed here Communications through our website or via email are not encrypted and are not necessarily secure. Use of the internet or email is for your convenience only, and by using them, you assume the risk of unauthorized use. By checking this box you hereby agreeI Agree SIGNATURE*DATE (mm/dd/yyyy) *
