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Please fill out this form as completely as possible. Doing so will
help Dr. Vitenas answer your questions more completely, and they will be answers
based on your actual wants, needs and personal history. Your information is private
and confidential. We hold your privacy in the highest regard, and suggest you read
our Privacy Policy to learn more about why we
need your information, and how we keep your personal information private.
This form, allows you to set up your initial consultation with Dr. Vitenas, or to
ask the doctor for more detailed information about what cosmetic surgery can do
for you.
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I am making this request because:
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I just started thinking about cosmetic surgery and welcome professional advice.
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I am new to the area and need to find a cosmetic surgeon.
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I am thinking about changing my doctor.
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I have consulted other cosmetic surgeons and am looking for someone better.
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What Cosmetic Procedures are you interested in?
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Wrinkle Removal
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BOTOX Cosmetic Injections
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Fat Injections
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Restylane
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Skin Repair
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Microdermabrasion
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Chemical Peel / Phenol and Trichloroacetic Acid (TCA)
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Laser Skin Resurfacing
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Dermabrasion
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Scar Repair / Scar Revision
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Birthmark Removal
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Mole Removal
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Breast
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Breast Enlargement / Augmentation Mammaplasty / Implants
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Breast Lift / Mastopexy
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Breast Implant Revision
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Breast Reduction
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Fat Removal
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Liposuction, Lipoplasty, Lipectomy and Liposculpture employ various suction, tumescent,
ultrasonic and ultrasound techniques to assist in removal of excess fat cells. My
problem areas are:
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Face ---
Neck ---
Arms ---
Body
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Back ---
Abdomen ---
Waist
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Thighs ---
Knees ---
Ankles
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Body
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Body Contouring lifts, tightens and tucks sagging muscle and skin. My areas of interest
are:
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Tummy Tuck / Abdominoplasty
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Arm Lift / Brachioplasty
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Thigh Lift / Leg Lift
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Body Lift / Bodylift / Circumferential Abdominoplasty
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Neck Lift
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Eyelids
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Eyelid Surgery / Blepharoplasty
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Face and Head
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Face Lift / Facelift / Rhytidectomy
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Nose Reshaping / Rhinoplasty
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Forehead Lift / Brow Lift / Browlift / Endoscopic
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Ear Surgery / Otoplasty
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Lip Augmentation
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Chin Augmentation / Implants / Genioplasty
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Cheek Augmentation / Implants / Malarplasty
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Male
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Male Breast Reduction / Gynecomastia
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Female
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Labiaplasty / Vaginoplasty
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How long have you been considering cosmetic surgery?
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Less than 1 month.
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1 to 6 months.
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More than 6 months.
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Have you consulted other doctors about cosmetic surgery?
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No
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Yes |
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Age:
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Gender:
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Female --
Male
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Please list any existing medical conditions or allergies you have:
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What is your expected budget:
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Less than $1,000
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$1,000 - $2,500
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$2,500 - $5,000
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$5,000 - $10,000
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$10,000 - $20,000
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$20,000 or More
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How much do you know about the cosmetic procedures you are considering?
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I just started my research.
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I have been researching for at least one year.
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I know someone who has had cosmetic surgery.
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I am ready to meet with the doctor to learn more.
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How soon are you considering having a cosmetic procedure?
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Within 1 month.
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Within 2 to 3 months.
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Within 3 to 6 months.
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After 6 months or more.
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I have not decided to have a cosmetic procedure.
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Height:
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Weight (In Pounds):
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Do you smoke?:
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No ---
Yes
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What questions you want Dr. Vitenas to answer about cosmetic procedures?
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YOUR CONTACT INFORMATION
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Name:
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I prefer to contacted by:
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E-mail ---
Phone --
No Preference
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Email Address:
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Telephone:
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Best time to call is:
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Submit Request:
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Blepharoplasty (Eyes)
Financing Options 
