Virtual Consultation Form

Please complete the form below for a preliminary, complimentary evaluation.

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

Virtual Consultation Form

  • Personal Profile

    Fields marked with * are required.

  • If you have some photos of yourself that you would like to share, please use the upload button below to upload photos to send to us:  To make the most out of your virtual consultation, do your best to submit your photographs in the following format. This will allow Dr. Kaufman to make the most comprehensive assessment.  Use a solid background. Take one frontal photo with the face or body centered and looking straight. Take at least one, preferably two profile photos.

    Example of a good photo
            Example frontal view
    Example of a good photo
            Example profile view
    Example of a good photo
        Example body frontal view
    Example of a good photo
        Example body profile view

    (Photos should not exceed 2 MB.)

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    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 to hold Kaufman Plastic Surgery, its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties.
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