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817.912.1410

240 Miron Dr.
Southlake, TX 76092

Serving all of Dallas, Fort Worth Areas

We would love to hear from you! Please fill out this form and we will get in touch with you shortly.

Patient Information:
Legal Full Name*
Phone Number*
Email Address*
Date of Birth*
Height (ft.)*
Height (in.)*
Weight (lbs.)*
Height Total
BMI
*BMI 30 or less is required for surgical safety.
Procedure(s) wanted:*
How soon do you want surgery?*
- ASAP
- Within 1 month
- Within 3 months
At my consultation this week, when I schedule my procedure I plan to pay:*
- $0 down
- $1,000 down
- More than $1,000 down
Nicotine/tobacco use:*
- Never
- Occasional
Any history of blood clots, bleeding disorders, autoimmune conditions (like Lupus or Crohn's disease), diabetes, or 3 or more miscarriages?*
- Yes
- No
Phone
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