Virtual Consultation

Virtual consultations are available only to patients outside a driving distance (approx 200 miles).

Thank you for your virtual consultation request! To help our providers accurately assess your needs, please include photographs showing the area of concern and ensure that the photos you send follow these guidelines: Photos must be taken by someone else (not selfies), against a solid background and at rest (not smiling). Please include clear, well-lit images of your eyes & face from multiple angles. Specifically, we need one head-on (straight view) photo and two side-angle photos (one from each side). This allows for a proper evaluation and helps us prepare personalized recommendations for your consultation.

Your Information

First Name* This field is required.

Last Name* This field is required.

Gender* This field is required.

Date of Birth* This field is required.

Phone* This field is required.

Email* This field is required.

State* This field is required.

ZIP Code* This field is required.

Procedure of Interest* This field is required.

Procedure Timing* This field is required.

List prior treatments (surgical and non-surgical) and when they were performed.* This field is required.

Have you had under eye filler? If yes, list when and list what product(s) if known.* This field is required.

Question / Message* This field is required.

Attach Files*

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File Upload

Hold the 'control' or 'command' key to select multiple files. Photos are required for virtual consultation.
Maximum combined file size is 20 MB.

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