Procedure interest

First Name

Last Name

Email *

Phone *

Date Of Birth *

Weight (lbs) *

Height (feet) *

Height (inches) *

Are you trying to lose weight before the procedure? *

My goals are... *

I'd like to schedule my treatment by:

Would you like an in-person or virtual consultation?

In-person

Virtual

If you selected a virtual consult, please upload photos below. Avoid iPhone "Live" photos, keep file sizes small, and note that uploads may take up to 15 seconds. Review the photo upload guidelines before you begin.

I have reviewed the photo upload guidelines.

Yes

Photo 1:

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF Please attach a photo that best shows your area of concern.

Photo 2

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF Additional photos help us understand your goals.

Photo 3

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

I authorize Dr. Austin Hayes and his staff to review the photos submitted here for the purpose of preparing for my consultation. I understand my photos will be kept confidential as part of my patient record.