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450 Sutter Street, Suite 1212, San Francisco, CA 94108 655 Redwood Highway Suite 250, Mill Valley, CA 94941

Uniquely You!

Virtual Consultation

1. Contact Information
2. Areas of Interest
3. Additional Information

First Name*

Last Name*

Phone*

Email*

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Facial Rejuvenation

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, Botox, 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.

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.

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?

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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:




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