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Complete the Form for a Free Virtual Gynecomastia Consultation

Are you tired of feeling self-conscious about your chest? Look no further - Dr. Jacobs, a world-renowned gynecomastia expert is offering FREE virtual consultations to patients in the USA and Canada. Completing the form may take a few minutes longer than expected, but what is a few minutes compared to an opportunity of a lifetime?

Let’s get started! Set aside 10 minutes to begin the process.

You will need to upload some images as well, so ask a trusted friend or family member to take these photos, or set up a self-standing tripod. Dr. Jacobs is thoroughly committed to your journey and wants to ensure he provides you with the best possible feedback during your free virtual consultation, hence the images.

Why wait? Let’s do this! Your free virtual consultation will be scheduled with Dr. Jacobs within 1 to 2 business days of receiving your completed form. You can trust us to respect your privacy, all information received is treated with doctor-patient confidentiality.

Contact Information

All fields marked with an asterisk (*) are required.

Preferred form of contact:

Welcome to the Free Virtual Consultation Form with Dr. Jacobs, specializing in Gynecomastia and related procedures. We understand the importance of your inquiries and assure you that all marked fields in this form are required to provide you with the most comprehensive consultation. Upon completion, your free virtual consultation will be promptly scheduled with Dr. Jacobs within 1 to 2 business days. We look forward to assisting you on your journey towards greater confidence and well-being.

All fields marked with an asterisk (*) are required.

Personal Information:

Lifestyle information:

Recreational drug/alcohol/tobacco use*

Any special diets (ie vegetarian, vegan)*

Medical information:

Medical History

Any past or present major medical conditions (ie diabetes, high blood pressure, asthma, sickle disease, heart, lung, kidney, liver problems, etc)*

Any prior major surgical procedures*

A brief personal medical history*

Any prior use of body building (anabolic) steroids or OTC supplements/prohormones, Propecia (Finasteride), etc, and dates of use*

Current medications (prescription or over the counter)*

Allergies to prescription medications, rubber (latex), and foods (particularly to soy and eggs)*

Condition background

Does anyone else in your family have this condition?*

Your history of gynecomastia (onset, duration, asymmetry, any recent changes, pain/tenderness, nipple discharge, any prior gynecomastia surgery, and details, etc)*

Any prior hormonal testing for gynecomastia*

A brief description of your goals for the operation*


Thank you for all the information you've shared so far.

I will need photos to complete the online consultation process.

  • Have them taken on an Apple or Android phone (not an SLR camera) with no flash.
  • They should be taken by another person or in the mirror
  • The images should include your neck to mid abdomen
  • Selfies don't work because they distort your chest.
  • Accepted file types: jpg, jpeg, png, gif
  • File size less than 255MB

Cost Information

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