Virtual Consultation Form

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First Name(Required)

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Date of Birth(Required)

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Weight

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Areas of Concern & Procedures You are Considering:(Required)

When are you hoping to have this procedure done?(Required)

Is there an event that is motivating you?

Have you had cosmetic surgery before?

Yes

If yes, please indicate surgical procedures

How long have you been thinking about cosmetic surgery?

On a scale of 1-10, how important is this surgery to you?(Required)

What are your expectations & concerns of this procedure?

Where are you in your decision-making process?

PLEASE USE THE UPLOAD BUTTON BELOW TO UPLOAD PHOTOS TO SEND TO US(Required)

Drop files here or

Accepted file types: gif, png, jpg, jpeg, Max. file size: 3 MB.

To make the most of your virtual consultation, do your best to submit your photographs in the following format. This will allow our doctors to make the most comprehensive assessment.
1. Use a solid background.
2. Take one frontal photo with the face or body centered and looking straight.
3. Take at least one, preferably two profile photos

File formats accepted: gif | png | jpg | jpeg
File size limit: 3mb

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Communications through our website or via email are not encrypted and are not necessarily secure. Use of the internet or email is for your convenience only, and by using them, you assume the risk of unauthorized use. By checking this box you hereby agree.

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TESTIMONIALS

"They have been so great with me. When you have a traumatic experience like a car accident, it is so refreshing to have medical professionals take such good care of you. Stacy is the best. She brightens up my day even when I'm in pain." - Kymberly B.
"I was apprehensive about the Epidural procedure; however Dr. Moheimani and all of his staff made me feel very comfortable and catered to making me less nervous both before and after the injection. Thank you, Dr. Moheimani!" - Gracie M.
"After having a high level of pain in my shoulders caused by a car crash Dr. Moheimani suggested PRP Injections. I did the injections and Dr and his team where fantastic and the results are great.I would highly suggest and refer Dr. Moheimani and also PRP." - Sean T.

Call today
to schedule a consultation

TESTIMONIALS

LOCATIONs

Call today to schedule a consultation

TESTIMONIALS

LOCATIONs

Call today
to schedule a consultation