Virtual Plastic Surgery Consultation

To begin your virtual consultation with Dr. LoVerme, fill out the form below. Depending upon your answers here you will be asked follow-up questions on the next page. You will also be able to upload photos for Dr. LoVerme to review.

Include as much information as you feel is necessary.

Required fields are marked with an asterisk *.

Your personal information will not be shared with, or sold to, anyone outside of our organization for any reason.

Title:
First Name: *
Last Name: *
Age:
Gender:
Height:
Weight:
Email: *
Day Phone: *
How would you like us to respond? Email Phone
Areas of Concern & Procedures You Are Considering:
When are you hoping to have this procedure done?


Is there an event that is motivating you?
Have you had cosmetic surgery before?
Yes No


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? *
What are your expectations of this procedure? What are your concerns? * Where are you in your decision making process? *
How were you referred to Accurate Aesthetics Plastic Surgery? Friend
Another Doctor
You have been a patient of ours
Radio
TV
Favorite TV Channel:
(Please check all that apply) *
Yellow Pages
Internet/Web
Bridal Show
Mall Show
Other (Night Club, Expo)
Other:

Please use the upload button below to upload photos to send to us:

To make the most out 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.
Example of a good photo
Example frontal view.
Example of a good photo
Example profile view.
Photo 1*:
Photo 2:
Photo 3:
Photo 4:

By checking this box you agree to the Terms of Use listed here:
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 to hold Accurate Aesthetics Plastic Surgery, its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties.


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