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With Dr. Dolores Fazzino, DNP, Nurse Practitioner
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Email *
Apply for Concierge Surgical CoachingTM
Patient First Name *
Patient Last Name *
Your FULL Name  and Relationship to Patient
If you are completing this request for a loved one having surgery- otherwise leave blank
Patient Address Line 1 (Street Address) *
Patient City, State, Zip (country if not the USA) *
Your Email (please verify typed correctly!) *
Your Cell Phone Number *
Your Skype handle (or N/A if you're not set up on Skype-YET) *
Date of Surgery *
NOTE:  If surgery is within a 2 week date from this request, an additional expediting fee may apply
How can Dr Dolores Fazzino best serve with the upcoming surgery? *
What are your fears or concerns? *
What are your desired outcomes for the surgical experience, healing, and overall wellness? *
A copy of your responses will be emailed to the address you provided.
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