Virtual Consultation Form

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Personal Information

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





What type of results are you hoping to achieve?

More AthleticYoungerHealthierCosmetic Correction

When are you hoping to have this procedure done?

Is there an event that is motivating you?

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 of a good photo
Example frontal view.
Example of a good photo
Example profile view.

Photo 1: Photo 2:

Photo 3: Photo 4:

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By checking this box you hereby agree to hold Argyle Plastic & Reconstructive 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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Argyle Plastic & Reconstructive Surgery

Board Certified Plastic Surgeon

1514 Fourth Street
Jackson, MI 49203

(800) 809-4320

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