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Civil status :   *Firstname :
*Lastname :   Birthdate :
*Address :
Zip code :   *City :
Country :   *Home phone :
email :   Cell phone :
Fax :      
 

 

Desired cosmetic surgery* : ( cross the appropriate box )

  The face : Eyelid surgery
 2 eyelids
4 eyelids
Nose surgery
Face and neck lift
 
  The silhouette : Hip liposuction
Tummy tuck
Other areas
 
  Breasts : Breast reduction
Breast enlargement
Breast lift
 
  Hair :  Capillary implants  
  Others :  
       
  Desired surgery date :  
 

Your comments :

 
 
* Please , fill up completely the appropriate boxes, to receive a response at your contact form.

 



Samy DLIMI, MD
Plastic , Reconstructive and Cosmetic surgery
Former of the New York, Paris and Brussels hospitals