Virtual Plastic Surgery Consultation in Miami & Miramar, FL

Title

First Name*

Last Name*

Age:

Gender:

Height:

Weight:

Email*

Phone*

How would you like us to respond?

Email
Phone

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

By checking this box you agree to the Terms of Use listed here:

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 to hold Dr. Wendell Perry and affiliates harmless from any hacking or any other unauthorized use of your personal information by outside parties.

Virtual Consultation