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Virtual Consultation

If it’s difficult for you to call us during your workday to get your consultation process started, you can complete this online initial consultation form.

We will review your form and your photos and call you promptly to answer your preliminary questions. If you’d like, you can schedule an appointment for a free consultation.

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

* Required fields are marked with an asterisk

First Name:*

Last Name:*

Zip Code:

Telephone:*

Age:*

Height:*

Weight:*

Bra Size:*

Your Goals

When are you hoping to have this procedure?*

Procedure you are considering*

What questions do you have?

What are you hoping this surgery will accomplish?*

About You

Have you had cosmetic breast surgery before?

Yes
No

If yes, what procedures?

Do you have children?*

Yes
No

If yes, date of birth of your last child.

Did you nurse your youngest child?

Yes
No

If yes, when did you stop?

Did/does your mother or sister have breast cancer?

Yes
No

Date of your last mammogram.

What medications do you take daily?*

Medical history (like thyroid, high blood pressure, diabetes, etc.)*

How did you hear about us?

Photos

Please attach 2 photos – shoulder to waist (no face) without a bra by using the “Choose File” buttons below. Photos are optional, but helpful.

Example of front view

Take a front view:

Take a front view:

Acceptable file types: doc,docx,pdf,txt,gif,GIF,jpg,jpeg,JPG,png,PNG.
Maximum file size: 10mb.

At least one arm should be down at your side.

Example of side view

Take a side view (either side is fine):

The arm on the side you are photographing should be down by your side.

I consent to having my information collected by Dr. Ted Eisenberg and Staff*

Free consultation 1-888-SHAPE-12

Free consultation
1-888-SHAPE-12

Virtual Consultation

Your Goals

About You

Photos

Call us for a free consultation at 1-888-SHAPE-12

or click here for a virtual consultation