Event Online Consultation - Dermatologists Of Birmingham

Schedule A Consultation

First Name*

Last Name*

Age*

Gender

Female

Male

Weight

Height

Phone

Email*

How would you like us to respond?

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 any cosmetic procedure before?

Yes

If yes, please indicate cosmetic procedures

How long have you been thinking about the cosmetic procedure?*

On a scale of 1-10, how important is this procedure to you?*

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

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

File*

Drop files here or

Accepted file types: jpg, pdf, gif, jpeg, png, Max. file size: 50 MB.

By checking this box you agree to the Terms of Use listed here*

I Agree

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

Signature*

Date*

Comments

This field is for validation purposes and should be left unchanged.

PLEASE USE THE UPLOAD BUTTON BELOW TO UPLOAD PHOTOS TO SEND TO US

2 Convenient Locations

Birmingham

Alabaster