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Plastic Surgeon Contact Form Please complete ALL fields! Do you have a question about cosmetic surgery? A concern about plastic surgery? By filling out this form, you understand and agree that: This is NOT a medical advice form! We are NOT medical professionals. If you are ill or believe you need a doctor, please contact your OWN physician immediately! You are granting permission for your information to be transferred to the office of a board-certified plasic surgeon near you. We are not responsible for any breaches of confidentially which may occur regarding your imformation (although we take normal precautions to ascertain that breaches do NOT occur!) No guarantees or any type are being made or implied regarding the delivery of or accuracy of response to anything on this form. Your Name: Nearest Large City: ZIP CODE: Phone Number........................................... Your E-mail Address...................................... Contact preference: Phone or E-Mail? Best time to contact you?...................................... Cosmetic surgery procedure (See list above) Other information? Your question or concern:: We cannot guarantee delivery of nor response to your query... Problems with the form? send an email to webmaster@boardcertifiedplasticsurgeon.com with all of the information above.   Privacy Policy: By filling out the form on this page and submitting said form, you are agreeing that you will not hold us liable for the dissimination of any or all of the information. We do NOT purposely share any submitted information with anyone other than a board-certified plastic surgeon or their office staff and/or representatives. However, you agree not to hold the webmaster or administators of this web site for the interception of misuse of any information which you submit, personal or otherwise. We do NOT collect personal information other than that submitted on forms. We do NOT share any information other than as previously indicated except for the quantity of visitors to this page and our site. Please read our entire Privacy Policy. Thank you! Return to our main page... BoardCertifiedPlasticSurgeon.com Copyright 2005 - 2009 by BoardCertifiedPlasticSurgeon.com (sm) All rights reserved

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