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Pre-Consult Questionnaire
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| As a "Thank You"
for your time in filling out this Pre-Consult Questionnaire, the
consultation for your anticipated Cosmetic Surgery will be complimentary. |
| In order to make
the most of you consultation with Dr. Hickman, we would appreciate
it if you would take a few moments to fill out the questions below: |
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| 2. |
How were you referred to us? |
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| 3. |
What procedure / procedures are you interested in discussing
with Dr. Hickman? |
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| 4. |
Why are you interested in having this particular procedure? |
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| 5. |
Are you interested in financing this procedure? |
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| 6. |
Do you have a price range in mind for this procedure? |
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| 7. |
Do you have a time frame in mind for scheduling this
procedure? |
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| 8. |
Please note any questions or concerns that you have about
this procedure |
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| Thanks Again, |
| Donn M Hickman,
M.D. and Staff |
4401 ATLANTIC
AVE, SUITE #101 LONG BEACH, CA. 90807
PHONE: (562) 422-5902 FAX: (562) 422-6014 |
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