Virtual Consultation Form

Virtual Consultation Form

arslanianplasticsurgery.com
Full Name*

First NameLast Name
DOB*

MonthDayYear
Date
Phone*
Email Address*
example@example.com
What procedures or treatments are you interested in?*
Has the area you are interested in treating ever been operated on (is this a revision)?*
What are your surgery goals?*
When would you like to have your procedure done?*
Height / Weight*
Do you smoke, vape, hookah, any nicotine products or marijuana? *
Do you have any past, present medical conditions or anything you take medication for?*
What is the most important thing for you when deciding on a plastic surgeon for your surgery?*
Are you interested in financing?*
How did you first hear about Arslanian Plastic Surgery?*
Where do you live?*
State*
Have you had any cosmetic surgery procedures?*
List cosmetic procedures:
Have you had any non-cosmetic surgery procedures?*
List non-cosmetic procedures:
What medications do you take?*
Are you a woman over 40 and considering any breast-related procedure ?*
Have you had a mammogram within the last year?
Do you have a history of high blood pressure or diabetes?
If 50 or older and planning any procedure, have you completed an EKG?*
Are you on any GLP-1 medications (Ex. Ozempic, Wegovy, Mounjaro)?
Do you have any allegies? *
List of allergies:
Have you had any significant weight gain or weight loss?
List your heaviest and lightest weight as an adult:
Photo Upload
In order to get you the most accurate virtual consultation, please follow these steps:

1. Please take photos in a well-lit room, preferably with natural light, against a plain background.

2. Please take photos in a two-piece swimsuit, or your bra and underwear. If interested in a breast procedure, please take a photo with no bra.
3. Please center the photos over the area you are interested in treating.

4. For body photos, please be 4-5 feet away from the camera.

5. For face photos, please take a photo with your entire face in the frame, no makeup or filters.

6. Upload at least the 3 views requested, and any additional photos as needed for other areas. To ensure smooth uploading, please make sure each image file is no larger than 5MB.
Front View*

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Side View Left*

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Side View Right*

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Additional Photo 1*

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Additional Photo 2*

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Should be Empty:

Virtual Consultation Form

Photo Upload