Christopher Costanzo MD Plastic Surgery

www.cosmeticsurg.com      www.doctorcostanzo.com
(805) 373-9919        (818) 706-2070       1-(866) 922-0212 toll free outside 805 & 818 area codes

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Age        Please fill in 18-25 yrs 26-35 yrs 36-45 yrs 46-55 yrs 56-65 yrs > 65 yrs                                    Gender         Female Male
Height    Please fill in < 5' 5'1"-5'5" 5'6"-5'9" 5'10"-6' > 6'                                     Weight    Please fill in < 100 lbs 100-125 lbs 126-140 lbs 141-160 lbs 161-180 lbs 181-200 lbs 201-250 lbs > 250 lbs
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I anticipate having surgery As soon as possible within 1 month 1-3 months 4-6 months

Procedure(s) Your Interested In (Press Control +Click or Command +Click to select multiple                                                                                                                                                  procedures)

Breast Implants Breast Lift & Implants Breast Reduction Breast Reconstruction Gynecomastia (male)	Brow Lift & Eyelids Facelift Rhinoplasty (nose) Otoplasty (ears) Chin Implant Facial wrinkles	Liposuction Tummy Tuck Arm Reduction Thigh Reduction Soft tissue fillers Laser, face peels

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