Virtual Consultation

A virtual consultation allows you to see the doctor virtually wherever you are, whether you’re stuck at home, out and about, or working hard in your office. You can conveniently see the doctor without interrupting your own busy schedule. Once you have completed all the required steps below and we have reviewed the information, we will contact you and confirm the day and time for your scheduled appointment.

Please follow these steps to have a successful Virtual Consultation with us.

First Name*
Last Name*
Phone*
Email*
Age*
Gender*
Height
Current Weight
Max Weight
City*
State*
How would you like us to respond?*
- Phone
- Email
Current Medications
Allergies
Pregnancies
Births
Preferred Physician*
Areas of Concern & Procedures You are Considering:*
When are you hoping to have this procedure done?*
Is there a reason that is motivating you?*
Have you had cosmetic & non-cosmetic surgery before?*
- Yes
- No
If yes, please indicate surgical procedures and the outcomes
Have you had non-invasive procedures (cool sculpting, silicone injections, threads, kybella, botox, fillers, lasers, etc) before?*
- Yes
- No
If yes, please indicate non-invasive procedures
Do you have any reactions to anesthesia (local, general, topical)*
- Yes
- No
If yes, please indicate what reactions
Do you have or had any facial / body implants?**
- Yes
- No
If yes, please indicate where you have them
Have you taken accutane in the last year?**
- Yes
- No
Please choose one or more areas of interest (hold the ctrl button on pc or command button on mac down when selecting multiple options)*
We have the ability to transfer your own fat to areas where volume is desired. Where (if any place) would you like the fat to be transferred? (hold the ctrl button down when selecting multiple options)
What are your expectations & concerns of this procedure?*
Where are you in your decision-making process?*
How were you referred to us? (Please check all that apply / hold the ctrl button down when selecting multiple options)*
Photos
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 one back photo with the body centered and straight. Facial procedures please take profile shots of each side of the face. 4. Take one photo of the front of your ID. File formats accepted: gif | png | jpg | jpeg File size limit: 2mb
File #1
Accepted file types: jpeg, jpg, gif, png.
File #2
Accepted file types: jpeg, jpg, gif, png.
File #3
Accepted file types: jpeg, jpg, gif, png.
File #4
Accepted file types: jpeg, jpg, gif, png.
By checking this box you agree to the Terms of Use listed here*
I agree
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
First & Last Name*
Date*
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