Dr. Scurlock Consultation Form

Dr. Scurlock Consultation Form

Thank you for considering me for your cosmetic procedure. This form was built and is being maintained to be HIPPA compliant. However, I respect that still stresses people out! Live virtual consultations are also available utilizing my electronic medical record software for storage of patient information.
Full name*
Email address*
Phone Number*
City*
State*
Do You Smoke?
Date Of Birth
Have you had any children, if so please let us know how many?
Previous Surgeries*
Current Medications*
Any Medical Conditions*
Procedures of Interest*
Preferred Date for surgery*
Please upload photos for your cosultation

When uploading photos for consultation please use a solid colored wall for the backround. Ideally, photos are taking with ample lighting. Please take photos from the front, side and back of whatever area you are interested in addressing.
Front*

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Left Side

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Right Side

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Back

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I agree & give my consent for virtual consultation. *
By clicking send you agree to the TERMS AND CONDITIONS and PRIVACY POLICY of FusionMD cosmetic surgery.
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