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Virtual Consultation Form

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First Name

Last Name

Age

Phone

Zip Code

Email

Are you a Brilliant Distinctions or Aspire Rewards member?

Yes

No

If 'Yes', please provide member number:

Are you at or close to your desired body weight?

Yes

No

Areas of Concern:

Face

Neck

Chest

Body Area: (describe below)

Describe Body Area:

Desired Procedure:

Are you interested in treatment for the following:

Unwanted fat or cellulite

Brown spots or sun damage

Rough or uneven skin texture

Wrinkling or skin laxity

When are you hoping to have this procedure done?

Upcoming Events:

Any health concerns you want to share with us?

Do you currently have any of the following?

Metal Implants

Pacemaker

Defibrillator

Mesh Implants

Other

If 'Other', please list:

Previous cosmetic procedures or surgeries and date?

Best Method to Contact You:

Phone

Email

For Insurance Cases Only*:

Insurance Member ID Number

Insurance /Provider Phone Number

*Dermatology & Laser of Del Mar does not accept Medicaid or HMO insurance plans. We do accept most PPO coverage and Medicare. While we do accept insurance for medical dermatology appointments, we cannot guarantee your visit will be covered. That is dependent on your individual plan. Cosmetic Procedures are not billed through insurance. These may be paid by cash, check or major credit card. We also accept financing through Care Credit.

Upload Photos

If you would like to include photos of yourself to assist in evaluating your individual case, you may add them here. Please keep in mind that photo submissions will not take the place of a face-to-face consultation with Dr. Atkin and additional photos may be requested depending on your procedure of interest. To achieve the best quality photos, please:

Use a solid color background
Take one front facing photo with the face and or body centered, looking straight
Take at least one profile photo from each side

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By checking this box you acknowledge that:

*Any evaluation performed via our website is for the purpose of assessing and educating for appropriate cosmetic procedures. Dermatology & Laser of Del Mar cannot dispense medical advice or treat any medical condition without being seen by a licensed provider.

*Communications through our website or via email are not encrypted and are not necessarily secure. Use of the Internet or email is for your convenience only, and by using them, you assume the risk of unauthorized use.

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Dermatology & Laser of Del Mar

12865 Pointe Del Mar Way, Suite 160
Del Mar, California 92014 Driving Directions

858.350.skin(7546)

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