Virtual Consultation Registration

Date

First Name:(Required)

Middle Initial:

Last Name:(Required)

Birth Date(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number:(Required)

How can we use your phone number?

You may leave a message
You may text
Do not leave a message

Email:(Required)

Skype Account:

If you would like to book a Skype consultation please list your Skype account name so that Dr. Parfitt can contact you.

FaceTime Number:

If you would like to book a FaceTime appointment with Dr. Parfitt please list the number he should use to call you.

Other Consult Request:

If you would like to video chat with something other than Skype or FaceTime please list the details here.

Occupation:

Does your job require strenuous activity or protective gear over your face?

Yes
No

How did you hear about us?

Referral Source. Please be specific. If more than one, please list which was most influential. Please list the first and last name of any person or professional who referred you. We have a great referral reward system!

Please list all allergies or sensitivities(Required)

Please list all allergies along with your reaction. If you do not have any allergies please type "None"

Please list all medication and supplements(Required)

Please list all medications your take including supplements. If you do not take any medications or supplements type "None".

Please list any chronic medical condition or important health history

Please describe any chronic health concerns or skin conditions.

Have you had any prior facial surgery?

Yes
No

If you have had prior facial surgery please describe what was done and when. Also describe if you were happy with the results.

What procedures or concerns would you like to discuss?

Please upload headshots to show your concerns.

Drop files here or

Max. file size: 256 MB, Max. files: 6.

HOW TO TAKE PHOTOS: – Another individual should take these photos of you – The photographer should be AT LEAST 6 feet away and ZOOM In from that distance so that the head fills the frame. – Stand in front of a blank wall or background – Photos should be full-face headshots (from top of head to collar) from the front and also the side – Do not smile in photos – Make sure photos are clear and not blurry or distorted -You may need to reduce the size of the image to successfully upload. If you are unable to upload photos to this form please email them to angela@facialplastics.com

Comments

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Patient Consultation Registration Form

PARFITT FACIAL COSMETIC SURGERY CENTER

MIDDLETON LOCATION

APPLETON LOCATION

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