Virtual Consultations Available

Telemedicine Consultations Available

We are available to schedule or reschedule appointments and Dr. Bednar is available for Telemedicine consultation. To schedule a Telemedicine consultation please call 704-366-6700 or email to sylvia@drbednar.com and our patient concierge will assist you in scheduling your appointment.

For new patients please complete the patient registration form below. Once you have submitted your registration form we will need you to upload your photos

Upon receipt of information, the office will contact you to set up a mutually convenient date/time for you and Dr. Bednar to connect to discuss any surgical procedure.

We thank you for your patients and cooperation during this difficult time.

First Name*

Last Name*

Age*

Gender

Weight

Height

Phone*

Email*

How would you like us to respond?

Phone

Areas of Concern & Procedures You are Considering:*

When are you hoping to have this procedure done?

Is there an event that is motivating you?

Have you had cosmetic surgery before?

If yes, please indicate surgical procedures

How long have you been thinking about cosmetic surgery?

On a scale of 1-10, how important is this surgery to you?

What are your expectations & concerns of this procedure?

Where are you in your decision-making process?

PLEASE USE THE UPLOAD BUTTON BELOW TO UPLOAD PHOTOS TO SEND TO US

To make the most of your virtual consultation, do your best to submit your photographs in the following format. This will allow our doctors to make the most comprehensive assessment.
1. Use a solid background.
2. Take one frontal photo with the face or body centered and looking straight.
3. Take at least one, preferably two profile photos

File formats accepted: gif | png | jpg | jpeg
File size limit: 5mb

Photos*

Drop files here or

Max. file size: 50 MB.

Consent*

I agree

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.
*By checking this box you hereby agree

SIGNATURE*

DATE*

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This field is for validation purposes and should be left unchanged.

Virtual Consultations Available

Telemedicine Consultations Available

PLEASE USE THE UPLOAD BUTTON BELOW TO UPLOAD PHOTOS TO SEND TO US

Schedule Your
Consultation Today!
704-366-6700

Park Place Medical Complex

439 N. Wendover Rd.
Charlotte, NC 28211