IMPLANTFORUM - AllAboutLipo - AllAboutPlasticSurgery - TopSurgeonsOnline

To qualify for a free consultation, please bring this form to your consultation.
(Please mention WEBSITE NAME upon making consultation appointment)

 

This states you were referred to me by one of the above websites (circle site).

Signed ________________________________ Date _______________________

Patient Name _____________________________________
City, State _____________________________________


Plastic Surgery Office reserves the right to reject any free consultation (this should be avoided if you call ahead and mention you
were referred by one of the above websites for your free consultation). If you forget to bring the free consultation form
to your consultation, the plastic surgery office may allow you to fax or mail it to them or bring it to them on another appointment or on
your surgery date, please consult your plastic surgery office to see what to do.
Free plastic surgery consult pretains to consults for plastic surgery only.