Skip to content

New Loyalty Rewards Program – Earn up to $750 in points for every referral

Home
About
Body
Breast
Vaginal
Face
Gallery
Influencers
Resources
Virtual Consult
Reviews
Contact

305.933.4033

Virtual Consultation

Home|Virtual Consultation

Full Name(Required)

Email(Required)

Phone Number(Required)

Address(Required)

Street Address City State ZIP Code

Date of Birth/Age(Required)

Height(Required)

Weight(Required)

What procedure are you interested in?

This field is hidden when viewing the form

Doctor

Do you have any medical problems? Please List them.

Have you had any previous surgeries? Please List them.

What medications do you take on a daily basis?

Do you smoke?

Yes

No

How much and for how many years

Are you interested in having multiple procedures done at the same time?

Yes

No

How do you plan to pay for the procedure?

Cash

Check

Credit Card

Apply for Financing

Are you interested in any type of breast surgery?

Yes

No

How many children have you had? 

Did you breast feed?

Yes

No

For how long on average

Do you plan on having children in the future? 

Yes

No

Have you had any problems with your breasts (such as cysts, lumps, abnormal discharge, skin changes, etc)?

Yes

No

Please list

Have any close relatives had breast cancer?

Yes

No

The last mammogram I had was:

What type of implants are you interested in?

What Bra size do you currently wear?

What cup size do you want to be after surgery (approximate)?

Upload your pictures

Drop files here or

Max. file size: 128 MB, Max. files: 5.

CAPTCHA

By submitting this form and signing up for email and texts, you consent to receive marketing emails and text messages (e.g. promos, exclusive discounts) from Elite Plastic Surgery at the email and number provided, including emails and messages sent by autodialer. Consent is not a condition of purchase. Msg & data rates may apply. View our Privacy Prolicy.

Phone

This field is for validation purposes and should be left unchanged.

Start your journey

First Name(Required)

Last Name(Required)

Email(Required)

Phone Number(Required)

Primary Procedure of Interest

Secondary Procedure of Interest

This field is hidden when viewing the form

Doctor

Comments

Untitled

Sign me up to receive news and specials

I accept the Terms of Use*Untitled

I accept the Terms of Use*

By submitting this form and signing up for email and texts, you consent to receive marketing emails and text messages (e.g. promos, exclusive discounts) from Elite Plastic Surgery at the email and number provided, including emails and messages sent by autodialer. Consent is not a condition of purchase. Msg & data rates may apply. View our Privacy Prolicy.

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

Useful links

Sign up for our newsletter!

Make an Online Payment

Join our Loyalty Rewards Program - Use code EPS12 for $250 in Points

Read our google reviews

Contact us

305.933.4033

Elite Plastic Surgery

2700 Hollywood Blvd. Suite #200

Hollywood, FL 33020

Home
About
Body
Breast
Vaginal
Face
Gallery
Blog
Contact

Save up to $2500! Your Dream Transformation with Dr. Salama Awaits

Sign up now to unlock VIP pricing on your dream procedure - up to $2500 off. Limited Time Offer.
Experience the perfect blend of luxury, precision, and artistry—because your transformation deserves the best!

Full Name(Required)

Email(Required)

Phone Number(Required)

Procedure(Required)

When are you looking to have surgery?(Required)

Surgical Budget Range(Required)

CAPTCHA

By submitting this form and signing up for email and texts, you consent to receive marketing emails and text messages (e.g. promos, exclusive discounts) from Elite Plastic Surgery at the email and number provided, including emails and messages sent by autodialer. Consent is not a condition of purchase. Msg & data rates may apply. View our Privacy Prolicy.

Name

This field is for validation purposes and should be left unchanged.

Contact Us

View Specials

Scroll to Top