Virtual Consultations | Plastic Surgeon Dr. Jon Ver Halen

Virtual Consultation Form

FullName*
LastName*
Mobile*
Email*
Age*
Gender*
Height*
Weight*
How would you like us to respond?*
- Phone
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Areas of Concern & Procedures You are Considering:*
When are you hoping to have this procedure done?*
Is 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?*
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?*
How were you referred to Dr. Ver Halen? (Please check all that apply)*
Photos
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 File size limit: 2mb
File #1
Accepted file types: jpeg, jpg, gif, png, Max. file size: 2 MB.
File #2
Accepted file types: jpeg, jpg, gif, png, Max. file size: 2 MB.
File #3
Accepted file types: jpeg, jpg, gif, png, Max. file size: 2 MB.
File #4
Accepted file types: jpeg, jpg, gif, png, Max. file size: 2 MB.
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