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Consultation

     
Note that any information submitted through this form is held in strictest confidence.
    Fields marked with * are mandatory
First Name*
Last Name*
Email*
Country
City and State
Phone*
Gender  

Female            Male
Age  
How did you hear about Dr Umar and FineTouch Dermatology Clinic   *
What is your problem area and what do you not like about that area?  
What surgical, medical or laser treatment have you tried for the problem in the past and what was the outcome? Give details including the doctor, date, satisfaction level etc.   Yes    No
Have you consulted with any dermatologist or plastic surgeon for the same problem (s) that brings you here today? If yes, give details including doctor, date, outcome of consultation   Yes    No
Are you currently being treated for any medical, surgical or psychological condition? If yes, please give details including medications you are currently taking etc.   Yes    No
Have you been treated for any medical, surgical or psychological condition in the past? If yes, please give details including medications you have taken in the past etc.   Yes    No
List medications you are currently taking  
List medications you have taken in the past  
List other surgeries you have had in the past  
What are your expectations from the procedure you are seeking today  
Approximate date you would prefer to have your procedure  
How would you like us to contact you   Email me an opinion
Email me for a date to see the doctor
Phone me for an appointment to see the doctor
If other, specify:  
Please send some of your photos for better evaluation.
Please make sure the photos don't exceed 5 Mb each.


   

 

 

This online consultation is not a reliable means of consultation and that any advise
and/or recommendation is subject to verification during an in office visit
and physical examination by Dr. Umar or associate.

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