Virtual Consultation Registration Form

Please provide all the information below and click “Submit and Checkout.” Check boxes and fields with an (*) are required.

First Name*
Last Name*
Best Time to Contact
Phone Number* Email Address*
Interested In*
Comments for the Doctor

* By checking this box and submitting this form, I certify that I have read and understood the following disclaimer: "The advice the patient receives from Pasadena Surgeons and Dr. Lakshman are suggestions based on his expertise, personal experience, and professional opinion. The cosmetic suggestions from Pasadena Surgeons in no way recommend or give approval to any medical procedures, use of medications or medical devices, or to embark upon medical care of any description. All recommendations should be shared with and approved by the patient's primary care provider/physician. It is imperative that the advice rendered be taken in the proper context of the patient's current health status, past medical history, current medications, and a thorough list of allergies and sensitivities. It is the patient's responsibility to consult with their regular doctor or pertinent medical specialist regarding the cosmetic suggestions of Pasadena Surgeons and Dr. Lakshman."

* By checking this box and submitting this form, I agree to the HIPPA Data Use Agreement and the Photography Use Agreement. Please review these agreements by selecting the links below.

Click Here to View HIPPA Data Use Agreement

Click Here to View Photography Use Agreement

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