VIRTUAL CONSULTATION

To expedite our service please fill out this form below. Thank you.

Patient information

Name*
Nombre Apellidos
Email*
Phone*
Country*
City*
State*
Zip Code:*
Date of Birth*
Height*
Unit (IN/CM)*
Weight*
Unit (LBS/KG)*
Do you smoke?*
Do you drink alcohol?*
Do you have children?*
Upload 3 to 6 Photos
Minumum 3 photos required. Front, side and angle.*
Suelta archivos aquí o
Tipos de archivos aceptados: jpg, jpeg, png.
Procedure of Interest*
Desired Surgery Date*
Previous Surgeries*
Current Medications*
Herbal Supplements or Vitamins*
Known Drug Allergies*
Any Medical Conditions*
Form terms*
Communications through our website or via email are not encrypted and are not necessarily secure. Use of the internet or email to communicate with Pure Plastic Surgery 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 Pure Plastic Surgery, its doctors, affiliates and vendors, harmless from any hacking or any other unauthorized use of your personal information by outside parties.
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Name
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