Virtual Consultation Form

Virtual Consultation Form

Thank you for your interest in Tampa Bay Body Sculpting, a world renowned Liposuction & Body Contouring clinic with over 20,000+ procedures, Dr. Robert Miles can get you to your body goals!We are happy to set up a surgical plan that fits your goals! All consultations are virtual at this time. We are happy to schedule a tele-consultation or an in office consultation after we receive your information. To begin your Virtual Consultation please reply with the following:
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Height *
ex. 5'0"
Weight *
Please upload photos of the area(s) for surgery: front, side, and back (in a 2 piece) *

Cancel of
Procedure(s) you are interested in, check all that apply: *

The Triple Crown Collection by Dr. Miles Liposuction The Signature Waist (Hourglass Contouring) Brazilian Butt Lift (BBL) Gluteal Liposuction/Monogram Glutes Mommy Makeover Chin Liposuction with Facial Contouring Chest Reduction/Gynecomastia Abdominal Sculpting (6 Pack Abs) Arm Liposuction/Autograph Arms Thigh Liposuction/Monogram Thighs Liposuction for Lipedema Breast Rejuvenation (Fat Transfer to Breasts) Breast Reduction/Lift Botox & Fillers Mini Face Lift Cellulite Reduction/Nonsurgical RF Treatments (skin tightening) Post Surgical Lymphatic Massage and Ultrasound Treatments Other
Have you had Cosmetic Surgery before? If so, please include what procedure you have had including area(s) for surgery, date(s) of procedure, and Dr. who performed the procedure: *
List any Medical Conditions: *
Are you allergic to any medication(s)? If so, please list. *

No Yes
Do you have any allergies including environmental and/or food allergies? *

No Yes
Please list all medications you are currently taking *
Do you smoke, drink, or do any drugs? *
Do you have current labs (Complete Metabolic Panel) within 3 months? *

Yes No
Wish date for surgery *

Month Day Year
Date
How did you hear about us? *

Google Website Instagram Facebook TikTok YouTube Previous Patient From a friend Other
Your location (City, State) *
Please enter your Instagram Name *
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