Virtual Consultations in Knoxville, TN | Trillium Plastic Surgery

A s an added precaution in response to the COVID-19 (Coronavirus) outbreak, Dr. Jason Hall and his team offer virtual consultations, in addition to regular, in-person consultations.

First name*

Last name*

Email address*

Phone Number*

Weight*

Height*

Date of Birth*

Procedure*

Medical History

Photo Submission (Front)*

Photo Submission (Side)*

Photo Submission (Back/or Side)

NOTE: If you are sending breast photos, please send a front view and two 90 degree side views.

HIPAA ACKNOWLEDGEMENT

Please be aware that this is a secure email network under HIPAA guidelines. Do not submit any personal or private information unless you are authorized and have voluntarily consented to do so. We are not liable for any HIPAA violations. Understand that if you email us, you are agreeing to the use of this secure method and understand that all replies will be sent by standard (unsecured) email, which you are hereby authorizing. By checking this box you hereby agree to hold Knoxville Plastic & Craniofacial Surgery, including its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties.

By checking this box, I acknowledge my understanding of the HIPAA Policy and agree with its contents.

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Virtual Consultations Trillium Plastic Surgery