Plastic Surgery Seattle | Cosmetic Surgery Bellevue

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Naficy Center

Cosmetic Surgery

Reconstructive

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You may use this form to request a consultation and/or treatment with any of our providers. For cosmetic surgery consultations with our surgeons there is a fee of $75, which is fully credited toward any cosmetic surgical procedure you choose to have. This fee is paid at the time of scheduling either by calling our office with your CC information or by using Paypal. Consultations for Reconstructive Surgery, Dermatology, and other medical problems are billable to insurance.

For all cosmetic surgery procedures you have the option to schedule a no-charge consultation with any one of our experienced patient care coordinators who can provide you with a great deal of information about the procedures, show you hundreds of before and after photos, provide you with cosmetic surgery price quotes, and if you so desire may take your photos to discuss with the surgeons.

After receiving your contact information, desired days or dates, and desired time frames, we shall contact you to notify you of available dates and times for your visit.

First Name:

Last Name:

Address:

City:

State:

Zip:

Email:

Day time phone:
Evening phone:

How do you wish to be contacted:

Email Phone Either

Schedule your appointment with:

	Dr. Naficy Rhinoplasty, Facial Plastic Surgery, Facial Reconstructive Surgery $75 cosmetic consult fee Reconstructive consults and procedures are billable to insurance
	Dr. Gottlieb Breast & Body Plastic Surgery, Body Reconstructive Surgery, Hand Surgery $75 cosmetic consult fee Reconstructive consults and procedures are billable to insurance
	Dr. Amadi Oculoplastic & Reconstructive Surgery, Orbital Surgery $75 cosmetic consult fee Reconstructive consults and procedures are billable to insurance
	Rhinoplasty & Facial Plastic Surgery Patient Care Coordinator No charge consultations for rhinoplasty & facial cosmetic surgery
	Breast & Body Plastic Surgery Patient Care Coordinator No charge consultations for breast and body contouring surgery
	Non-Surgical Consultation with a Provider No charge consultations for injections, lasers, and other non-surgical options offered M - F
	Non-Surgical Treatment with a Provider Appointments for injections, lasers, and other non-surgical treatments offered M - F

Date and Time of Appointment:

First Preference:
Date: Time:

Second Preference:
Date: Time:

Third Preference:
Date: Time:

How soon are you considering having the procedure(s) performed?

I would like to have the treatment on the same day as the
consultation
I know exact time frame
Dates: From To
Within few weeks
Within few months
Within a year
Unsure/Just considering my options

Type of service(s) you are considering:
(check all that apply)

Facial Surgery:	Body Surgery:	Non-Surgical:
Rhinoplasty	Breast Augmentation	Botox or Dysport
Revision Rhinoplasty	Saline Breast Implants	Fat Injection
Face Lift	Silicone Breast Implants	Dermatology
Mini Face lift	Breast Reduction	Restylane
Neck Lift	Breast Lift (Mastopexy)	Sculptra
Mini Neck Lift	Breast Revision	Radiesse
Neck Liposuction	Breast Cancer Reconstruction	Juvederm
Septoplasty	Liposuction of Arms	Perlane
Nose Reshaping	Liposuction of Abdomen	Artefill
Brow Lift	Liposuction of Back	Fotofacial
Eyelid Lift	Liposuction of Flanks	Intensive Fotofacial
Ptosis Repair	Liposuction of Thighs	Laser Vein Removal
Cheek Lift	Liposuction of Knees	Treatment of Age Spots/Freckles
Chin Implant	Male Breast Reduction	Thermage for Face
Cheek Implant	Arm Lift	Thermage for Body
Feather Lift	Tummy tuck	Thermage for Cellulite
Laser Resurfacing	Mini Tummy Tuck	CoolSculpting
Facial Fat Grafting	Thigh lift	Sclerotherapy
Lip Augmentation	Buttock Lift	Laser Hair Removal
Ear Reshaping	Lower Body lift	Microdermabrasion
Buccal Fat Removal	Body Fat Grafting	Vi Peel
Facial Skin Cancer	Body Skin Cancer	Retinoic and Glycolic Peel
Facial Scar Revision	Body Scar Revision

Additional comments:

Optionally include photos (up to 4 images, each image must be less than 2 MB in size) to help with discussion:

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Plastic Surgery Seattle | Cosmetic Surgery Bellevue

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Schedule a Consultation