Virtual Consultation 1. Contact Information 2. Areas of Interest 3. Additional Information First Name Last Name Phone Email Facial Rejuvenation Facial Procedures Please tell us what area(s) of your face you are looking to improve. Please list them in order of importance to you. Please tell us what is bothering you about those areas. Please be as specific as possible. Have you ever had any traumas or injuries to your face? Have you ever had any surgical or nonsurgical treatments performed on your face (facelift, blepharoplasty, lasers, peels, fillers, etc.)? If so, please list them, and please include approximate dates of procedures. What facial rejuvenation/skin care treatments are you interested in? Are you interested in surgical or nonsurgical treatment options (or both)? What is your ultimate goal with these treatments (i.e. want to look younger, look more refreshed, feel better about yourself, etc.)? Please list your goals in order of importance. Have you had a prior consultation with a plastic surgeon, and if so what was recommended? What special concerns do you have regarding cosmetic surgery? What factors do you consider important in your decision about having cosmetic surgery? What qualities do you consider important in your cosmetic surgeon? What do you want to accomplish in your consultation with the doctor? When are you hoping to have your procedure(s) performed? What do you feel may be the long-term benefits of your cosmetic surgery? Please tell us any other relevant information that will help our team to develop the best treatment plan for you. Body Contouring Body Contouring Please tell us what area(s) of your body (i.e. abdomen, flanks (sides), back, inner thighs, outer thighs, buttocks, arms, etc.) you are looking to improve. Please list them in order of importance. Please tell us what is bothering you about those areas. Please be as specific as possible. Have you ever had any surgical or nonsurgical treatments performed on your body? If so, please list them, and please include approximate dates of procedures. What body contour procedures are you interested in? Are you interested in surgical or nonsurgical treatment options (or both)? What is your ultimate goal with these treatments (i.e. flatter abdomen, thinner thighs, weight loss, feel better about yourself, etc.)? Please list your goals in order of importance. How concerned are you about surgical scars on your body (i.e. not concerned, mildly concerned, extremely concerned, etc.)? Have you had any weight gains or losses? Is your weight stable or are you planning on losing weight? What is your height and weight? (Women) Have you had any children and if so how many? Have you had a prior consultation with a plastic surgeon, and if so what was recommended? What special concerns do you have regarding cosmetic surgery? What factors do you consider important in your decision about having cosmetic surgery? What qualities do you consider important in your cosmetic surgeon? What do you want to accomplish in your consultation with the doctor? When are you hoping to have your procedure(s) performed? What do you feel may be the long-term benefits of your cosmetic surgery? Please tell us any other relevant information that will help our team to develop the best treatment plan for you. Nasal Surgery Nasal Surgery Please tell us what is bothering you about your nose (i.e. bump/hump, crooked, tip too wide, trouble breathing, too long, etc). Please be as specific as possible. Do you have any trouble breathing through your nose? Have you ever had any traumas or injuries to your nose? Have you ever had any surgical or nonsurgical treatments performed on your nose? If so, please list them, and please include approximate dates of procedures. What nasal procedures are you interested in? What is your ultimate goal with these treatments (i.e. want to improve your breathing, nasal appearance, feel better about yourself, etc.)? Please list your goals in order of importance. Have you had a prior consultation with a plastic surgeon, and if so what was recommended? What special concerns do you have regarding cosmetic surgery? What factors do you consider important in your decision about having cosmetic surgery? What qualities do you consider important in your cosmetic surgeon? What do you want to accomplish in your consultation with the doctor? When are you hoping to have your procedure(s) performed? What do you feel may be the long-term benefits of your cosmetic surgery? Please tell us any other relevant information that will help our team to develop the best treatment plan for you. Breast Procedures Breast Procedures Please tell us what is bothering you about your breasts (i.e. too small, too large, sagging, etc). Please be as specific as possible. Please list them in order of importance. Have you ever had any surgical treatments performed on your breasts? If so, please list them, and please include approximate dates of procedures. What is your current bra cup size and what bra cup size do you want to ultimately wear? What breast procedures are you interested in? What is your ultimate goal with these treatments (i.e. fuller breasts, lifted breasts, smaller breasts, relief of back pain, feel better about yourself, etc.)? Please list your goals in order of importance. How concerned are you about surgical scars on your breasts (i.e. not concerned, mildly concerned, extremely concerned, etc.)? Have you had any weight gains or losses? Is your weight stable or are you planning on losing weight? (Women) Have you had any children and if so how many? Have you had a prior consultation with a plastic surgeon, and if so what was recommended? What special concerns do you have regarding cosmetic surgery? What factors do you consider important in your decision about having cosmetic surgery? What qualities do you consider important in your cosmetic surgeon? What do you want to accomplish in your consultation with the doctor? When are you hoping to have your procedure(s) performed? What do you feel may be the long-term benefits of your cosmetic surgery? Please tell us any other relevant information that will help our team to develop the best treatment plan for you. Other Concerns Other Concerns Please tell us what area(s) you are concerned about. Please list them in order of importance. Please tell us what is bothering you about those areas. Please be as specific as possible. Have you ever had any surgical or nonsurgical treatments performed on this area? If so, please list them, and please include approximate dates of procedures. What procedures are you interested in? Are you interested in surgical or nonsurgical treatment options (or both)? What is your ultimate goal with these treatments? Please list your goals in order of importance. How concerned are you about surgical scars (i.e. not concerned, mildly concerned, extremely concerned, etc.)? Have you had a prior consultation with a plastic surgeon, and if so what was recommended? What special concerns do you have regarding cosmetic surgery? What factors do you consider important in your decision about having cosmetic surgery? What qualities do you consider important in your cosmetic surgeon? What do you want to accomplish in your consultation with the doctor? When are you hoping to have your procedure(s) performed? What do you feel may be the long-term benefits of your cosmetic surgery? Please tell us any other relevant information that will help our team to develop the best treatment plan for you. Upload as many images as you feel necessary in order to communicate your concerns: del del del del Add file Validate CAPTCHA
