Virtual Consultations - Kaniff Cosmetic Medical Center

“Please be advised that by providing this form for you to contact our office(s), we are not confirming an appointment nor establishing a physician-patient relationship. As a user of this mode of communication and of our website, you assume all risks with placing confidential information into this portal. Our office will follow up with you within 24 to 48 hours business hours. This form of communication is not intended for acute, emergency, or life- threatening health conditions. If you believe you are having a health emergency, contact 911 or go to your nearest emergency department.”

Prospective patients get the best experience with an in person consultation at our Center where they get a “feel” for the environment, staff and Dr. Kaniff. While not a substitute for an in person consultation, we are happy to offer virtual consultations as a convenience for patients and their busy schedules..

Our virtual consultation services are available during specific business hours.

Virtual Consultation Form

First Name*
Last Name*
Phone*
Email*
Age*
Gender*
Height*
Weight*
How would you like us to respond?*
- Phone
- Email
Areas of Concern & Procedures You are Considering:*
When are you hoping to have this procedure done?*
Is there a reason that is motivating you?*
Have you had cosmetic surgery before?*
- Yes
- No
If yes, please indicate surgical procedures
How long have you been thinking about cosmetic surgery?*
On a scale of 1-10, how important is this surgery to you?*
What are your expectations & concerns of this procedure?*
Where are you in your decision-making process?*
How were you referred to Dr. Kaniff? (Please check all that apply)*
Photos
To make the most of your virtual consultation, do your best to submit your photographs in the following format. This will allow our doctors to make the most comprehensive assessment. 1. Use a solid background. 2. Take one frontal photo with the face or body centered and looking straight. 3. Take at least one, preferably two profile photos File formats accepted: gif | png | jpg | jpeg File size limit: 2mb
File #1
Accepted file types: jpeg, jpg, gif, png, Max. file size: 5 MB.
File #2
Accepted file types: jpeg, jpg, gif, png, Max. file size: 2 MB.
File #3
Accepted file types: jpeg, jpg, gif, png, Max. file size: 2 MB.
File #4
Accepted file types: jpeg, jpg, gif, png, Max. file size: 2 MB.
By checking this box you agree to the Terms of Use listed here*
I agree
Communications through our website or via email are not encrypted and are not necessarily secure. Use of the internet or email is for your convenience only, and by using them, you assume the risk of unauthorized use. By checking this box you hereby agree
Full Name*
Date*
Opt into our Newsletter?
- Yes
- No

Virtual Consultation Form

Photos

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