Miklos and Moore Labiaplasty Inquiry

VIRTUAL CONSULTATION INFORMATION
Thank you for your interest in Miklos & Moore Urogynecology.
We understand that distance is a key factor in your decision when choosing your surgeon.
SECURE SUBMISSION

Please see the directions below if you would like to securely submit your photos for review by the surgeon of your choice:

Photo Instructions:
Turn your camera to forward-facing view
Set camera timer to 3 seconds or 10 seconds
Take 2 pictures while on your back with your legs open (as if you were on an exam table)
Take 1 picture in your normal standing position
*It is important not to pull or distort your skin*

Upload 3 photos:
Photo1

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Photo 2

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Photo 3

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Name

First NameLast Name
Date of Birth
Email
example@example.com
Type a question
Phone Number

Area CodePhone Number
Best Time to Contact You *
MANDATORY QUESTIONS TO BE ANSWERED
Preferred Physician:

Dr. John R. MiklosDr. Robert D. MooreNo preference
Desired Surgical Timeline

0-3 months6-9 months9-12 months
Desired Location

AtlantaBeverly HillsCharlestonDubai
Physician/Patient phone consultation availability: *
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I, *
Your Name
certify that I am 18 years of age or older, and understand that I am submitting these photos of my own accord, soley for the purpose of medical evaluation.
Signature

Clear
Date *
Atlanta Office ~ 11975 Morris Road ~ Suite 140 ~ Alpharetta, GA 30005

Beverly Hills Office ~ 150 South Rodeo Drive ~ Beverly Hills, CA 90212

Charleston Office ~ 260 W. Coleman Blvd. ~ Suite A ~ Mt. Pleasant, SC 29464

Main Phone: (678) 573-6965 Fax: 877-509-0690 www.miklosandmoore.com
Type a question
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VIRTUAL CONSULTATION INFORMATION