Schedule | CHANCE + Co Plastic Surgery and Aesthetics

First Name* This field is required.

Last Name* This field is required.

Date of Birth* This field is required.

Sex* This field is required.

Phone* This field is required.

Email* This field is required.

Address* This field is required.

City* This field is required.

State* This field is required.

Zipcode* This field is required.

Best time to contact you* This field is required.

How did you hear about Dr. Chance?* This field is required.

Height* This field is required.

Weight* This field is required.

Are you in the process of losing weight?*

Yes

If so, how many pounds are you from your goal weight?

Are you currently taking Ozempic, Wegovy, Mounjaro or any other semaglutide product for weight loss?

Are you interested in hearing more about our weight loss program?*

Yes

What medical conditions do you have?* This field is required.

Current medications* This field is required.

Allergic to any medications?* This field is required.

Do you currently smoke tobacco?* This field is required.

Have you ever used tobacco products?* This field is required.

When are you interested in having surgery?* This field is required.

What cosmetic or functional surgeries have you had in the past? Please list procedure and date of service* This field is required.

Did you experience any complications from these procedures? If so, please explain below:

Are you pleased with your previous plastic surgery or aesthetic procedures? If you were not, please explain below:

Have you ever had threads, and if so, when were they placed?

Have you ever had Ultherapy, Thermage or Morpheus8?

This field is required.

I understand that Dr Chance's fee for her signature Deep Plane Facelift and Deep Structural Necklift ranges from $85,000 - $100,000.*

Thank you so much for taking the time to provide this information. So much care, thought and attention to detail goes into the consultation and surgical process with Dr. Elizabeth Chance and her team. We are grateful for your contribution to this process and look forward to communicating with you.

In order to complete and submit your form, please upload digital photos of your face and neck for assessment by Dr. Elizabeth Chance and her team. High quality photos are integral to make accurate, detailed assessments in order to optimize remote cosmetic consultations. Please find a room with good natural light and a neutral background and have a helper photograph you from the distance of a few feet. Pull your hair back for photos. The lens of the camera should be at eye level and your chin should be parallel with the floor. Please ensure that your face and neck are within the frame of the picture. Thank you!

*PDF or JPG Files only (Total File Size must be under 20mb)

Front* This field is required.

Left Profile* This field is required.

Right Profile* This field is required.

Left Oblique* This field is required.

Right Oblique* This field is required.

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Please note, communications through our website or via email are not encrypted and are not necessarily secure. By submitting this form, you are granting Chance + Co Plastic Surgery and Aesthetics permission to review your photos. These photos will only be used in-house for consultation purposes.*

Consultation Request for Dr. Chance