Virtual Plastic Surgery Consultation in Miami & Miramar, FL

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First Name:*

Last Name:*

Age:

Gender:

Height:

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Email*

Phone*

How would you like us to respond?

Email
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Areas of Concern & Procedures You Are Considering:

When you hoping to have this procedure done?

Is there an event that is motivating you?

Have you had cosmetic surgery before?

Yes
No

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 of this procedure? What are your concerns?*

Where are you in your decision making process?*

How were you referred to Dr. Perry?

Friend
Another Doctor
You have been a patient of ours
Radio
TV

(Please check all that apply)

Yellow Pages
Internet/Web
Bridal Show
Mall Show
Other

Please use the upload button below to upload photos to send to us:

To make the most out 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.

Use a solid background.
Take one frontal photo with the face or body centered and looking straight.
Take at least one, preferably two profile photos.

photo 1*

photo 2

photo 3

photo 4

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Virtual Consultation