Consultation Request- Bellevue Plastic Surgeons
Dr. Marosan- Bellevue Plastic Surgeons
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Email *
In order to schedule a consultation please complete and submit this form. If you have a specific question you wish to ask there is a field in this form where you can ask your questions and we will reply back to you. You will not be able to schedule a consultation until the form is completed. There is usually a 2 week waiting time from the time you request your consultation until booking. Upon receipt of the form we will offer you available consultation dates. *
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Bellevue Plastic Surgeons uses HIPAA compliant imaging software -TOUCHMD- that requires a valid email address. All other medical forms and quotes will also be available to you via our TOUCHMD HIPAA compliant portal which is available via mobile app or desktop access. You will receive a welcome email from MYTOUCHMD to access the portal once your consultation is scheduled. Bellevue Plastic Surgeons does not use your email for any promotional or spamming purposes. If you have entered an invalid email address on this form, now is the time to correct it. *
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First Name *
Last Name *
Date of Birth *
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Height *
Weight *
Telephone Number: *
Zipcode *
Bellevue Plastic Surgeons performs elective procedures only and does not accept insurance or assist with codes or billing insurance. *
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Which cosmetic procedure are you interested in? *
What body areas would you like to discuss with the doctor? *
Are you seeking to improve the results of a previous surgery or procedure? *
Have you had previous surgery in the areas of concern? *
If you had previous surgery/procedure in the area of concern, how long ago was the surgery/procedure?
How soon are you looking into having your procedure done? *
What is your intended budget to address your areas of concern? *
How will you pay for your procedure? *
Dr. Marosan sees patients for consultations on Mondays and Wednesdays. Once we receive the completed form we will provide you with a few available dates and times for a consultation. There is usually a 2 week waiting time from the time you request your consultation until booking. Do you prefer Mondays or Wednesdays? *
Bellevue Plastic Surgeons charges a non-refundable $150 consultation fee. The consultation fee gets applied towards the cost of the procedure. An invoice from noreply@payjunctionmail.com will be sent to you requesting payment. Your appointment for a consultation with Dr. Marosan will be confirmed upon receipt of payment. If you do not show for your scheduled consultation and do not cancel via email or text message within 48 business hours of your appointment, we will apply the consultation fee monies into a no show fee. *
Required
Bellevue Plastic Surgeons will provide you with a quote for the procedures discussed within 3-5 business days after your consultation. Quotes do not guarantee booking or agreement to perform surgery. *
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Do you have any more questions that we may answer? *
Due to Covid-19 safety measures we do not allow guests to accompany you during your consultation with the surgeon. Guests will not be allowed to enter the office. You must wear a mask during your consultation. *
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A copy of your responses will be emailed to the address you provided.
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