Mohs Surgery | Skin Cancer Treatment



 
Naficy Plastic Surgery & Rejuvenation Center
Trust your face to a specialist.


Schedule a Consultation

If you would like to have Dr. Naficy assist you in evaluation, removal and/or reconstruction of your skin cancer, you may contact us by submitting this form. A member of our nursing staff will contact you at a convenient time and perform a telephone interview.

First Name:
Last Name:
Address:
City:
State:
Zip:
Email:
Day time phone:
Evening phone:

I want to see Dr. Naficy for my skin cancer removal and/or reconstruction because (please choose one of 3 options):

I am a previous patient
Dr. Naficy was suggested by my doctor
I want to have a plastic surgeon do my surgery

Location of the cancer:


Has a biopsy been performed?

 No      Yes


How do you wish to be contacted:

 Email      Phone      Either

Date and Time of consultation:

First Preference:
Date: Time:

Second Preference:
Date: Time:

Third Preference:
Date: Time:

How soon are you considering having the procedure(s) performed?

As soon as possible
I know exact time frame
       Dates: From To
Within few weeks
Within few months
Unsure/Just considering my options


Additional comments:


Optionally include photos (up to 4 images, each image must be less than 2 MB in size) to help with discussion:
If you receive an error message, or have difficulty with the photo upload, you may e-mail photos, contact information, and question to information@seattleface.com

Photo 1:
Photo 2:
Photo 3:
Photo 4:

    



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Naficy Plastic Surgery & Rejuvenation Center     1110 112th Ave NE Suite 150 Bellevue, WA 98004     (425) 450-0880