Request a Teleconsultation

Teleconsultation Request
Welcome to Gorgeous Getaways !

Your Destination Manager will confirm available dates/times for your teleconsultation.

Keep in mind that your medical history and photos are a requisite to be a candidate for teleconsultation.
Lead Source
Have you completed a medical form prior?

Yes, please use my existing information No, I will complete the attached
Requested Teleconsultation Date

Month Day Year
Date
Requested Start Time

: Hour Minutes AM/PM Option
End Time

: Hour Minutes AM/PM Option
Duration
Sessions are in 15 minute increments. 15, 30, 45 and 60 minutes
Indicate Your Time Zone

Patient Information

Please complete the information below
Name *

First Name Last Name
Patient Gender *
Patient Birth Date *

Month Day Year
Age *
Nationality *
Height *
Weight *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number

Area Code Phone Number
Mobile Number *

Area Code Phone Number
E-Mail *

Surgery Details

Please tell us the procedures you are interested in
Preferred Destination *
If destination not listed, please indicate
Preferred Hospital or Clinic (If Known)
If hospital not listed, please indicate
Do you have a preferred surgeon?
Is this for gender transition surgery? *

No Yes
How long have you been on hormone therapy?
Can you provide a referral letter from your psychologist, sex therapist or psychiatrist

No Yes
If yes, please upload your referral letter

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Treatment Category
Requested Procedure(s) *
Requested Procedure(s)
Requested Procedure(s)
If not mentioned above please add treatments
What are your personal goals for having surgery
Anything you want to ask to the Surgeon?
When are you planning to have your surgery done ?
Arrival Date

Month Day Year
Date
Requested Date of surgery *

Month Day Year
Date

Photos or Files

Please upload your photos securely.
Please upload your photos as per the instructions below. These will be sent to the surgeon for feedback and confirmed price. Once your firmquote is ready, the teleconsultation will be scheduled.

The following are guidelines for submitting photos your photos:

1) Breast Augmentation and Breast Lift photos must be taken without undergarments from the neck to the waist with both arms down by the sides, as if standing to attention:

Left Profile
Right Profile
Front On
Back on

2) Facelift, Necklift and Rhinoplasty photos must show head and neck:

Left Profile
Right Profile
Front On
Head Tilted Backwards
Head Tilted Downwards

3) Mommy Makeover, Tummy Tuck, Liposuction and Brazilian Butt Lift photos must be taken without undergarments from the neck to the feet, with both arms down by the sides, as if standing to attention:

Left Profile
Right Profile
Front On
Back On

4) Thigh Lift Photos must include:

Left Profile – Showing Inside Thigh
Right Profile – Showing Inside Thigh
Left Profile – Showing Outside Thigh
Right Profile – Showing Outside Thigh
Front On
Back On

5) Arm Lift Photos must include front photos:
Left Arm - Raised At Side Of Body
Right Arm - Raised At Side Of Body
Photo/File Upload

Upload Files

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