Plastic Surgery Seattle | Cosmetic Surgery Bellevue



 
Naficy Plastic Surgery & Rejuvenation Center


Trust your face to a specialist.

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Schedule a Consultation

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:

Photo 1:
Photo 2:
Photo 3:
Photo 4:

    



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Naficy Plastic Surgery & Rejuvenation Center     1110 112th Ave NE Suite 150 Bellevue, WA 98004     (425) 450-0880