Virtual Consultation Form If you are having a medical emergency please call 911 or go to the Emergency Room nearest to you. New Patient Inquiries First Name *Last Name *Age *Gender MaleFemalePhone *Email *How would you like us to respond? Home PhoneCell PhoneEmailAreas of Concern & Procedures You are Considering: Any medical issues or medications you are taking? When are you hoping to have this procedure done? *ASAP3 Months6 Months +Is there an event that is motivating you? Have you had cosmetic surgery before? YesNoIf yes, please indicate surgical procedures How long have you been thinking about cosmetic surgery? *Less than 3 monthsAbout 6 months1-2 yearsMore than 2 yearsOn 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? I'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 nowTo make the most of your virtual consultation, do your best to submit your photographs in the following format. This will allow our doctor to make the most comprehensive assessment. 1. Ensure your lighting is good and your photos are clear and in focus. If possible, have someone take them for you. 2. Take one frontal photo with the face or body centered and looking straight. 3. Take at least one, preferably two, photos of the area(s) of concern.Photo 1 *Photo 2 Photo 3 Photo 4 By checking this box you agree to the Terms of Use listed here *General information is presented, and is not establishing a physician patient relationship nor is it specific to your concerns. General information is presented for educational purposes. 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 agree.I AgreeSIGNATURE *DATE (mm/dd/yyyy) * VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank:
