Virtual Consultation 2.0 DRAFT "*" indicates required fields First Name* Last Name* Phone*Email* Gender*GenderMaleFemaleDate of Birth* Height* Weight* How would you like us to respond?* Phone Email Areas of Concern & Procedures You are Considering:*When are you hoping to have this procedure done?*ASAPWithin 3 monthsWithin 6 monthsIs there a reason 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?*Less than 3 monthsAbout 6 monthsMore than a yearOn 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?*I'm just starting to think about itI've started researching procedures and doctors in my areaI've done my research, but I have more questionsI've decided I want the procedure, I'm just waiting for a good timeI'm ready to book my procedure nowHow were you referred to Georgia Plastic? (Please check all that apply)*FriendAnother DoctorYou have been a patient of oursRadioSocial MediaGoogleOtherTo 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 at least one, preferably two profile photos File formats accepted: gif | png | jpg | jpeg File size limit: 2mbCopy of Driver's License or Passport*Accepted file types: jpeg, jpg, gif, png, Max. file size: 2 MB.File #2Accepted file types: jpeg, jpg, gif, png, Max. file size: 2 MB.File #3Accepted file types: jpeg, jpg, gif, png, Max. file size: 2 MB.File #4Accepted file types: jpeg, jpg, gif, png, Max. file size: 2 MB.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 agreeFull Name* Date* Click Below to Choose Your Provider* Dr. Pallavi KumblaDr. Stanley OkoroDr. Daniel ParkPhysician AssistantHiddenQuantity*Total Payment MethodPayPal Checkout MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name
