Virtual Consultation Form

Title: Mr.Mrs.Ms.Dr.

Gender: ---MaleFemale

What type of results are you hoping to achieve?

More AthleticYoungerHealthierCosmetic Correction

When are you hoping to have this procedure done? Please select a time frame:Within 1 Month1-2 Months3-6 Months6 Months or more

Is there an event that is motivating you? Please select an event:WeddingClass ReunionBirthdayFamily ReunionNone of these

Have you had cosmetic surgery before? YesNo

How would you like us to reply? EmailPhone

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 Dr. Sampson to make the most comprehensive assessment.

1. Use a solid background.
2. Take one frontal photo with the face centered and looking straight.
3. Take at least one, preferably two profile photos.

Example frontal view.

Example profile view.

Photo 1: Photo 2:

Photo 3: Photo 4:

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