Virtual Consultation -

First Name*

Last Name*

Age*

Weight

Height

Phone*

Email*

Areas of Concern & Procedures You are Considering:*

When are you hoping to have this procedure done?*

Is there an event that is motivating you?

If yes, please indicate surgical procedures

How long have you been thinking about cosmetic surgery?*

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 list all present medications, including birth control pills, hormones, and vitamins, herbal medication, diuretics, weight loss drugs. Include over-the-counter medications.

Which?*

If yes, when and where?*

When?*

If so, how much?*

For how long?*

When was you last normal menstrual period?

How many pregnancies?

Births?

For how long?*

CHILDREN (gender and ages/birthdays)

When was your last physical exam?

By whom?

When was your last eye examination?

By whom?

When and where was your last chest x-ray?

EKG?

Who is your personal physician, if any? (Please list all physicians presently caring for you)

When & Why?*

Where?*

Is there anything else you think the doctor should know?

Please list all hospitalizations and surgeries, including procedures done for cosmetic reasons:

SURGICAL OPERATIONS (include where, when and why for each surgery)

HOSPITALIZATIONS (include where, when and why for each admission)

PLEASE USE THE UPLOAD BUTTON BELOW TO UPLOAD PHOTOS TO SEND TO US*

Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 20 MB.

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 | jpeg File size limit: 3mb

If you are interested in a breast augmentation, chin augmentation or rhinoplasty, we offer virtual simulations of possible results.

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