Virtual Consultation

Name*

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Age*

Gender

Current Height*

Current Weight*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Email*

Phone*

How would you like us to respond?

How were you referred to Dr. Alexander's Private Office?*

Have you had Cosmetic Surgery before?

If yes, please indicate Procedure and Year

Have you had surgery of any kind under general anesthesia?

If Yes, what year?

Are you currently taking any medications?

If yes, please list: Medical Condition, Medication Name, & Dose

Have you had children?*

If yes, how many?

Are you a smoker?

What Procedure(s) are you interested in?

Please tell us more about the areas of concern and what do you hope to accomplish with this procedure?

Guidelines to upload your photos:

How important is this surgery to you?

What would influence your decision to have this surgery?

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