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Chicago's #1 Rated Plastic Surgery

Consultation Request Form

Consultation Request

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Comments

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Name*

Email*

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Phone*

Date Of Birth*

MM/DD/YYYY

Please Select a Procedure*

Select a category first, then the procedure of interest

Please List Other Procedures Are Interested In (leave blank if none)

Doctor or Provider Preference*

Appointment Preference*

NOTE: Virtual Appointment Requests Must Submit Photos.

Decision Stage*

Height*

Weight (pds)*

How Did You Hear About Us?*

Tell Us More About Your Goals*

List Any Additional Procedures or Treatments you are Considering

Attach Your Photos for a Virtual Consultation & Faster Evaluation

Please upload 3-4 photos for virtual consultation requests. You can see our guidelines at the bottom of this page.

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 50 MB, Max. files: 10.

CAPTCHA

Opt-in For Discount Offers

I would like to receive occasional promotional offers & discounts from Chicago Breast & Body Aesthetics and affiliates.

Yes

Opt-in For Text Messages*

By selecting this box, you agree to receive recurring promotional SMS messages for appointment reminders, marketing messages, and general two-way communication from Chicago Breast & Body Aesthetics at the mobile number you provided. Up to 2–4 msgs/month. Msg & data rates may apply. Reply STOP to opt out. Reply HELP for help. Consent is not a condition of purchase. Refer to our Privacy Policy and Terms of Service for more information.

Yes

Type these words to prove you're a real person: "The sky is blue" (the SUBMIT button will appear).*

TERMS & CONDITIONS
Chicago Breast & Body Aesthetics Patient Care Coordinators will review the information you submitted and will respond to your inquiry. If you are a good surgical candidate, you will receive an estimated quote and next available consultation openings. Your final quote and surgical plan will be determined during a formal consultation with your surgeon. *Please note that restrictions apply for virtual consultations, as certain procedures or requests can only be evaluated in-person and are only offered with certain providers.

Chicago Breast & Body Aesthetics consultation form is protected and encrypted. The data you send will be securely transmitted to our office through the use of an encrypted email. However, it is important to remember that all data transmitted electronically will carry risks.

Chicago Breast & Body Aesthetics, its employees, and any affiliated third parties will not be held responsible in the event that the personal information submitted on this consultation form is illegally compromised through a hack on our servers. All your personal information is confidentially kept and will not be distributed to any parties or organizations outside of our office.

Office Hours

Monday

9:00 AM - 5:00 PM

Tuesday

9:00 AM - 5:00 PM

Wednesday

9:00 AM - 5:00 PM

Thursday

9:00 AM - 5:00 PM

Friday

9:00 AM - 5:00 PM

Saturday

Closed

Sunday

Closed

Appointment Etiquette & Policy

A valid credit card is needed to book an appointment due to limited availability.
Late Cancellation / No Show Policy: Appointments may be cancelled 2 business days prior to your scheduled appointment. No shows & late cancellations less than 2 business days prior to your scheduled appointment time are subject to a non-refundable $100 late cancellation fee/no show fee.

You may see more details on our appointment policy here.