Virtual Consultation Form

Consult with Marina Plastic Surgery in the Privacy of Your Home!

So many of our patients fly in from across the country and around the world that we've developed the Virtual Consultation. The virtual consultation allows you to share information about your current condition and desired surgical outcomes with Dr. Stevens and Dr. Stoker, before you fly to Los Angeles for surgery.

Step 1: Fill out the short form below. If you'd like, include 4 "before" photos to be evaluated by the doctors.
Step 2: Download, print and fill out our four Patient Information forms.
Step 3: Fax or mail your completed forms to our office.

Step 1 of 2

Required fields are marked with an asterisk *.

Title:
Your First Name: *
Your Last Name: *
Age:
Gender:
Email: *
Day Phone: *
Areas of Concern:
What procedure are you interested in?
When are you hoping to have this procedure done?
To discourage SPAM, we ask that you type your code (displayed below) in the text box.
Your Code:
Enter Code: *

If you have some photos of yourself that you would like to share, please use the upload button below to send them to us. For best results:

Use a solid background.
Take one frontal photo with your body or face centered and facing forward.

Example frontal view.	Example frontal view.
Example side view.	Example side view.
Photo 1:	Photo 2:
Photo 3:	Photo 4:

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