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Virtual Consultation Form

Contact Us

During your Orlando cosmetic surgery consultation, you will receive a wealth of information about your procedure and we're making it even easier for you to get started by scheduling a virtual consultation from the privacy of your own home. Your Virtual Consultation is complimentary and offers you an opportunity to get more detailed, customized information regarding procedures with Dr. Spence before you visit our office.

Due to the volume of patients that visit with us from out of town each year, we hope that our Virtual Consultation process will provide the most and best information possible and help you in making the right choices.

Please complete every field.

PERSONAL PROFILE

First Name: Last Name:
E-mail: Phone Number:
Best way to reach you: Email Phone
Best time to call/contact: Morning Mid-day Afternoon Evening Other:
Mailing Address: City:
State: Zip: Country:
Do you smoke? Yes No Sex: Female Male
Birth Date (mm/dd/yyyy): Height: Weight:

PROCEDURE INTEREST & HISTORY

Main Procedure Interest:
Other procedures: Budget:
Financial Assistance Required: Yes No Timeframe for surgery:
Have you had plastic surgery before? Yes No List previous surgeries or major illness and dates:

OTHER

How did you hear about Dr. Spence?
Questions/Comments:
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If you have some photos of yourself that you would like to share, please use the upload fields below to send them to us. To make the most out of your Virtual Consultation, please read and follow our photo instructions. This will allow the doctors to make the most comprehensive assessment.

Example of a good photo
Example frontal view.
Example of a good photo
Example back view.
Example of a good photo
Example profile view.
Example of a good photo
Example 45° view.
Photo 1:
Photo 2:
Photo 3:
Photo 4:
Photo 5:
Photo 6:

Privacy

I have read and understand the Privacy Policy.

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Terms of Use

By checking this box you agree to the Terms of Use listed here:

Communications through our website or via email are not encrypted. Use of the Internet or email is for your convenience only.

By checking this box you hereby agree to hold Dr. Kenrick Spence, his doctors and affiliates, harmless from any unauthorized uses of your information by outside parties.