VIRTUAL CONSULTATION

Our board-certified plastic surgeon in New Jersey can review your goals for rhinoplasty with information submitted via our virtual consultation form.

This information will ultimately go directly to Dr. Christopher Godek, where he can evaluate your needs and expectations before scheduling an in-person consultation. If you would like to initiate a virtual consultation, please fill out the fields below. If you would rather go ahead and schedule your personal consultation with Dr. Godek, please contact our office and we will be happy to assist you.

First name*

Last name*

Email address*

Age*

Phone Number*

Address*

City*

State*

Zip Code*

Are you Planning to Finance Your Procedure

Yes

No

Tell me if I am pre-qualifed to finance my procedure with PatientFi:

Yes

No

Height (ft.)*

Height (in.)*

Weight (lbs.)*

Areas of Concern:

Face

Breast

Body

Desired Procedures

Please Select a Time Frame: Within 1 Month 1-2 Months 3-6 Months 6 or More Months

Please Select an Event: Wedding Class Reunion Birthday Family Event Other

Any health concerns you want to share with us?

Previous plastic surgery and date?

Best Method to Contact You:

Phone

Email

Preferred Location for Consultation

Toms River

Wall

For Insurance Cases Only:

Provide Insurance Member ID Number

Insurance/Provider Phone Number

If you would like to include photos of yourself to assist in Dr. Godek's review, you may add them here. 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

Photo 1

Photo 2

Photo 3

Photo 4

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*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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