Miami & Fort Lauderdale, Florida: 954.565.7575 - 800.274.LIPO

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Virtual Consultation Form

Getting started with your Florida plastic surgery transformation is easier than ever thanks to our Virtual Consultation form. From the comfort of your own home, you can provide us with essential information to help us evaluate your candidacy for the procedures that interest you.

Please take the time to fill out this form as completely and accurately as possible. One of our staff members will be in touch with you to review your case, ask additional questions, discuss fees and scheduling, and address any concerns you may have. Thank you for your interest in cosmetic procedures at the South Florida Center for Cosmetic Surgery.

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 reply? Email Phone
Waist: *
 Hips: *
Bust: *
 Thighs: *
Areas of Concern & Procedures You Are Considering:
What type of results are you hoping to achieve?
More Athletic
Younger
Pre-Baby Body
Healthier
Cosmetic Correction
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:
Have you had surgery of any kind under general anesthesia?
Yes No
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? * Is your spouse or significant other supportive of you having surgery? *
What things will affect your decision to have surgery? *
 Where are you in your decision making process? *
How were you referred to The Florida Center?
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:

What other facilities (doctors) have you seen?
 What is your income level?
What type of work do you do? *
 How do you anticipate paying for the procedure?
Have you had children?
Yes No

 If yes, how many?
Other notes:

If you have some photos of yourself that you would like to share, 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:

To discourage SPAM, we ask that you type your code (displayed below) in the text box.

Your Code: Use this image to validate this form.
Enter Code: *

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 the South Florida Center for Cosmetic Surgery, its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties.
Fort Lauderdale
915 Middle River Dr., Suite 213
Ft. Lauderdale, FL 33304
(954) 565-7575
(800) 274-LIPO		 North Miami
9000 NE 2nd Ave
North Miami, FL 33138
(954) 565-7575
(800) 274-LIPO

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Copyright © 2010 South Florida Center for Cosmetic Surgery

South Florida Center for Cosmetic Surgery features surgeons specializing in liposuction in Miami. They also perform tummy tuck (abdominoplasty), breast lift, breast enlargement, breast reduction, nose shaping (rhinoplasty), face lift and blepharoplasty (eyelid surgery) as well as offer a full menu of medical spa services. They have two convenient locations in South Florida in Miami and Fort Lauderdale and serve patients from all over the world.

THE PATIENT AND ANY OTHER PERSON RESPONSIBLE FOR PAYMENT HAS A RIGHT TO REFUSE TO PAY, CANCEL PAYMENT, OR BE REIMBURSED FOR PAYMENT FOR ANY OTHER SERVICE, EXAMINATION, OR TREATMENT THAT IS PERFORMED AS A RESULT OF AND WITHIN 72 HOURS OF RESPONDING TO THE ADVERTISEMENT FOR THE FREE, DISCOUNTED FEE, OR REDUCED FEE SERVICE, EXAMINATION, OR TREATMENT.