January 2022 | Radiance Plastic Surgery

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Consultation Request

First Nameyour first name

Last Nameyour last name

Phoneyour full name

Emaila valid email

Date of Birth (YYYY/MM/DD)YYYY/MM/DD

Weight (Lbs)Weight (Lbs)

Height (Ft/In)Height (Ft/In)

GenderGender

Biological Sex at BirthSex

Do you have valid Canadian Healthcare?

YesNo

Are you a cigarette smoker or do you use e-cigarettes with nicotine (vape)?

YesNo

Are you pregnant, planning a pregnancy (in the next 12 months), or breastfeeding?

YesNo

How soon are you interested in receiving surgery?

How can we help?more details

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