Cosmetic Gynecology Dallas Online Phone Consultation

Thank you for your interest in Cosmetic Gynecology of Dallas. We understand that expertise is a key concern when considering your procedure. This online consultation form will allow you to safely and securely send pictures of the area(s) of concern. This form is HIPAA Compliant, and data is encrypted, so your privacy is not compromised.

After filling out the questionnaire, please follow the directions below if you would like to securely submit your photos for review by Dr. Nathan Thomas

1. Turn your camera to forward-facing view

2. Set camera timer to 3 seconds or 10 seconds

3. Take 2 pictures while on your back with your legs open (as if you were on an exam table) 4. Take 1 picture in your normal standing position *It is important not to pull or distort your skin*

Full Name*

Date of Birth*

Date

Age*

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Please select the procedure you are interested in having done, then answer the related questions.

LABIAPLASTY

Labiaplasty MinoraLabiaplasty Majora

How long has your labia minora / majora been bothering you*

Do they cause you discomfort?*

YesNo

Are you self-conscious?*

YesNo

Does it cause an altered appearance in tight clothing?*

YesNo

(For Labia Minora Only) Do you want to reduce the size of your Clitoral Hood as well?*

YesNo

VAGINAL REJUVENATION

Non-surgical TreatmentSurgical Treatment

Photo Upload 1: Max file size 2 MB - jpg, png, and pdf formats allowed*

Photo Upload 2: Max file size 2 MB - jpg, png, and pdf formats allowed*

Photo Upload 3: Max file size 2 MB - jpg, png, and pdf formats allowed*

Best Time to Contact to Schedule Consultation*

Best Time for Phone Consultation*

How soon are you hoping to have the Surgery?*

Street Address*

Apartment or Suite #

City*

State and Zip*

Your full name*

, certify that I am 18 years of age or older, and understand that I am submitting these photos of my own accord, soley for the purpose of medical

Signature*

Date*

Date

Women's HEALTH

ONLINE CONSULTATION FORM