Virtual Consultation Request

Whether you’re located nearby or anywhere around the globe, our virtual consultation option allows you to meet with Dr. Benjamin Liliav from the comfort and privacy of your own home. During your consultation, you’ll have the opportunity to discuss your aesthetic goals, receive expert recommendations, and learn about the procedures that best fit your needs.

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Virtual Consultation Form

To help us prepare for your consultation, please complete the information below. Providing accurate details will allow Dr. Benjamin Liliav to better understand your goals and medical history before your appointment.

Personal Details

"(Required)" indicates required fields

First Name(Required)

Last Name(Required)

Email(Required)

Phone(Required)

Address(Required)

Street Address City State Zip Code

Do you currently smoke or use nicotine products?(Required)

Date of Birth(Required)

Age(Required)

Height-Ft(Required)

Height-In(Required)

Weight-Lbs(Required)

This field is hidden when viewing the form

Height Calc

Body Mass Index (BMI)

Use the BMI calculator after entering your age, height and weight. Please make sure age, height and weight are entered before calculating your BMI.

Medical Background

Have you been pregnant or had children?(Required)

Please indicate the number of children.

Surgical History(Required)

Current Medications(Required)

Medication Allergies(Required)

Medical History(Required)

Treatment Goals(Required)

Procedures of Interest(Required)

Photo Submission (Required)

To complete your virtual consultation request, photo uploads are required. For the most accurate assessment, please submit clear, high-quality photos taken in a well-lit area against a plain white or neutral-colored background. Images should clearly show the area(s) you would like Dr. Liliav to evaluate.

Front Photo Upload *(Required)

Max. file size: 50 MB.

Back Photo Upload *(Required)

Max. file size: 50 MB.

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