Consult Request Form

The fee for consultations is 20 dollars. After submitting this form, you’ll be able to choose a time on our calendar and will be charged for the consultation at that time. In-person visits are available upon request.

First Name *

Last Name *

Date of birth *

Gender *

Male
Female
No elements found. Consider changing the search query.
List is empty.

Phone *

Email *

Address

State

Postal code

Main Concern

What procedures are you interested in (select all that apply)

Liposuction/Liposculpture
BBL
Abdominoplasty (Tummy Tuck)
High Definition
Breast Augmentation
Breast Lift
Skin Tightening
Back Lift
Vaginoplasty
No elements found. Consider changing the search query.
List is empty.

Height (inches)

Weight (lbs)

How did you hear of Dr. Gelb?

Would you like an in person consult?

Yes
No
No elements found. Consider changing the search query.
List is empty.

Front

Upload Photo

Left Side

Upload Photo

Right Side

Upload Photo

Back

Upload Photo

Is there anything else you would like Dr. Gelb to know?

I opt-in to be contacted by SMS (recommended). By checking this box, you agree to receive SMS messages from Formari related to this consultation request and further related communication. You may reply STOP to opt out at any time. Reply to HELP to (305) 395-5567 for assistance. Messages and data rates may apply. Message frequency will vary. Learn more on our privacy policy page and Terms & Conditions.

No I do not consent

Signature *

I attest all of the above information is correct

Privacy Policy | Terms of Service