Telehealth Consultation

First Name *

Last Name *

City *

State *

ZIP Code *

Country (other than USA)

Phone Number *

Email *

Referred by

Age *

Height *

Weight *

What are your concerns?

HIPAA ACKNOWLEDGEMENT

Please be aware that this is a secure email network under HIPAA guidelines. Do not submit any personal or private information unless you are authorized and have voluntarily consented to do so. We are not liable for any HIPAA violations. Understand that if you email us, you are agreeing to the use of this secure method and understand that all replies will be sent by standard (unsecured) email, which you are hereby authorizing. By checking this box you hereby agree to hold RL Center For Cosmetic Surgery & Med Spa, including its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties.

User Consent *

By checking this box, I acknowledge my understanding of the HIPAA Policy and agree with its contents. *

Enter the correct answer: *

Comment