Surgery request form

Thanks for your interest. I am happy to help you find the best date possible for your procedure. You can use this form to send me the information I need in an e-mail.

Your name

Your e-mail address

Patient's date of birth (including year)

IMPORTANT: SPELL the month. (12/4 can mean December 4 or April 12. Don't make me guess.)

Time of birth

(Make sure you indicate a.m. or p.m.)

City/County of birth

In what city will the surgery take place?

What's the general nature of the surgery? What part of the body does it involve?

What's the timeframe for surgery-- must it be done ASAP, or could it wait a few months?

Please list the dates that your surgeon is available.

IMPORTANT: You will need to contact the surgeon's office and find out this very important piece of information before you contact me. Please be as thorough and specific as possible.

Payment Please send me a Paypal invoice. I have made payment via Paypal. Please send me your mailing address so I can send a check. I am requesting a fee waiver.

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