Virtual Consultation

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HOW TO SCHEDULE YOUR VIRTUAL CONSULTATION

Fill out the request form.
We’ll contact you to talk about your consultation.

First Name *

Last Name *

City *

State *

ZIP Code *

Country (other than USA)

Phone Number *

Email *

Referred by

Age *

Height *

Weight *

What are your concerns?

How long have you been thinking about cosmetic surgery? *

Is there an event that is motivating you?

Have you had cosmetic surgery before? *

If yes, please indicate surgical procedures

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? *

Method of Response

HIPAA ACKNOWLEDGEMENT

Please be aware that this is a secure email network under HIPAA guidelines. Do not submit any personal or private information unless you are authorized and have voluntarily consented to do so. We are not liable for any HIPAA violations. Understand that if you email us, you are agreeing to the use of this secure method and understand that all replies will be sent by standard (unsecured) email, which you are hereby authorizing. By checking this box you hereby agree to hold Florida Plastic Surgery and Medspa, including its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties.

User Consent *

By checking this box, I acknowledge my understanding of the HIPAA Policy and agree with its contents. *

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