Dr. Gelb Consultation Form

Consult Request Form

Fill the form below and we will get back soon to plan your appointment with Dr. Gelb.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Address

CityState / Province

Postal / Zip Code
Date of Birth*

DayMonthYear
Gender*
Have you had surgery with Dr. Gelb before?*

YesNo
What procedure or procedures are you interested in?
What’s your main concern or goal—what would you like to improve or change?
When are you hoping to have surgery?
Weight and Height
Do you have any medical conditions?
What are your current medications?
Do you have any allergies?
Have you had any surgeries before? (cosmetic or other)
Do you currently smoke or use nicotine in any form?
Have you had any recent illnesses?
Do you have any relevant family medical history? (e.g., anesthesia problems, clotting disorders)
Consultation Photos

Please upload photos from the front, left and right sides and back, against a solid background with good lighting and from the same angle.
Front

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Back

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Left

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Right

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Is there anything else you would like Dr. Gelb to know?
Appointment
How did you hear of Dr. Gelb? If through a prior patient of his, please provide name.
Preferred Language*

EnglishSpanishOther
SMS consent*

Yes. I opt-in to be contacted by SMS (recommended) By checking this box, you agree to receive SMS messages from Formari related to this consultation request and further related communication. You may reply STOP to opt out at any time. Reply to HELP to (305) 395-5567 for assistance. Messages and data rates may apply. Message frequency will vary. Learn more on our privacy policy page and Terms & Conditions.No I do not consent
Visit https://www.stevengelbmd.com/terms-of-service-hippa-privacy-policy for privacy policy and https://www.stevengelbmd.com/terms-of-service-hippa-privacy-policy for Terms of Service.
I attest all of the above information is correct *

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Consult Request Form

Consultation Photos