Schedule a Consultation

Please provide the following contact information (optional except for e-mail):

E-mail (required)
Name
Address 1
Address 2
City
State/Province
Zip/Postal code
Country
Phone
Fax

Please provide some information about the surgery you are interested in:

Type	Cosmetic Reconstructive
Area/Location	Face Forehead Eyes Cheeks Nose Mouth Lips Chin Neck Chest Breast Abdomen Hips Legs Ankles Feet Other
Type of Change	Revise Reduce Enlarge
Problem (please be specific)

Please provide the following scheduling information:

Month/Date	(1st Choice)
	(2nd Choice)
Day of Consultation:	Monday Tuesday Wednesday Thursday Friday (1st Choice)
	Monday Tuesday Wednesday Thursday Friday (2nd Choice)
Time (PST)
Language	English French German Spanish Italian Japanese Chinese Other (specify)

Please provide the following billing information:

Credit card	VISA MasterCard
Cardholder name
Card number
Expiration date

Dr. Edward Jonas Domanskis is a plastic surgeon licensed to practice medicine in the state of California and certified by the American Board of Plastic Surgery. Your video consultation will be done by Dr. Domanskis in his office in California and any surgical procedure would be performed in California licensed Facilities. By your request you agree that there can be no claim against Dr. Domanskis for the video consultation without a subsequent live consultation and/or surgery in California and agree and understand that the video consultation is being done for convenience only.