Photo Consultation

Submit your photos and information below. We will review your submission to help determine your candidacy and provide you with additional information. Upon submission, someone from our office will be following up with you shortly.

Required fields:

First Name *

Last Name *

Mobile *

Email *

Height *

Weight *

Date of birth *

Body Areas of Interest *

Face

Breast

Midsection

Thighs

Buttocks

Which Procedures are you currently interested in? *

Upload your photos below:

Right Side View Photo

Front View Photo

Left Side View Photo

Back View Photo

Optional Fields:

Approximate date you would like your surgical procedure?

Instagram Handle

How did you hear about us?

Family
Friend
Staff
Website
Google
Facebook
Instagram
Drive-by
Other
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Occupation

Surgical History

All Medications

Past and Ongoing Medical Problems

Do you smoke?

Yes

No

If you smoke, select all that apply

Cigarettes

Vape

THC

Other

Do you drink Alcohol?

Yes

No

If you drink alcohol, how many drinks per week?

Are you pregnant?

Yes

No

Number of Children

Any additional information you would like to share:

Communication:

By checking this box, you agree to receive text messages from Dr. Stan Plastic Surgery for communication and booking. Please refer to our privacy policy. You can reply STOP to opt-out at any time. Message and data rates may apply. Messaging frequency may vary.

HITECH disclaimer *

Communications through our website or via email are not encrypted and there is risk to the confidentiality of your health information. The internet is an open network and provides no inherent protection for confidential information. By submitting this form, you accept these risks and waive the requirements under the HITECH Act for us to communicate with you.

Privacy Policy

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