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Virtual Consultation Form

  • How would you like us to respond?

  • Areas of Concern & Procedures You are Considering:
  • When are you hoping to have this procedure done?

  • Have you had cosmetic surgery before?

  • Is there an event that is motivating you?

  • 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?

  • PLEASE USE THE UPLOAD BUTTON BELOW TO UPLOAD PHOTOS TO SEND TO US To 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

  • 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

  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.

Written by Dr. Andre Berger

Rejuvalife Vitality Institute