CONTACT INFORMATION: (COMPLETE ALL FIELDS)

First Name:* Last Name: * Sex: * Male Female   Address: *   City: * State: * Select State: Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Labrador Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory Zip Code: * Phone: * E-mail: * Procedure: * ----- Select a Procedure ----- Select Procedure (if available): Arm Lift Body Lift (Thigh, Hip, Buttocks) BOTOX® Injections Breast Augmentation Breast Augmentation - Adjustable Saline Breast Lift Breast Reconstruction Breast Reduction Calf Implants Cheek Implant Chemical Peel Chin Implant Cleft Lip and Cleft Palate Collagen Injection Dermabrasion Ear Surgery (Otoplasty) Eyelid Surgery (Blepharoplasty) Facelift Facial (Chin, Cheek and Jaw) Implants Facial Surgery-Facelift and Forehead Lif Forehead Lift (Brow Lift) Hair Restoration Laser Skin Resurfacing Lip Augmentation - Alloderm Graft Lip Augmentation - Autologen Injection Lip Augmentation - Collagen Injection Lip Augmentation - Dermalogen Injection Lip Augmentation - Dermis-Fat Graft Lip Augmentation - Fat Injection Lip Augmentation - Gortex Graft Lip Augmentation - Local Flaps Inside th Lip Augmentation - Local Flaps Outside t Liposuction Liposuction - Traditional Liposuction - Tumescent Liposuction - Ultrasound-Assisted Male Breast Reduction (Gynecomastia) Microdermabrasion Neck Lift Nose Surgery (Rhinoplasty) Pectoral Implant Permanent Makeup Scar Revision Skin Resurfacing (Dermabrasion, Microder Spider and Varicose Vein Treatment Spider Vein Treatment Tattoo Removal Thigh Lift Tummy Tuck (Abdominoplasty) Doctor: * Dr. Douglas Gervais Dr. Richard Tholen No preference Questions / Comments: NOTICE: The message sent with this form is not considered secure. It sends an email to the recipient. Do not send confidential info or anything you would be uncomfortable sending by email.

FINANCING: (CHECK ONLY ONE)

I may want to find financing. I have applied for financing. I do not need financing.

WHEN: (CHECK ONLY ONE)

I'm likely to have this procedure sometime in the next year. I'd really like to get this done in the next 4 months. I'd consider coming in for a personal consultation after receiving more information. I'd like to set up a consultation soon.

THANK YOU: