APPOINTMENT SCHEDULE
Name:
E-mail:
Telephone:
City:
Country:
Gender:
Female
Male
Is this your first appointment with our clinic?
Yes
No
When was your last appointment? Year:
What is the main reason for your appointment?
Face
Mouth
Eyes
Nose
Body Contour
Mammary Region
Ears
Baldness
Reconstructive Surgery
Other treatments
If your previous answer was "other treatments", please specify:
Write below any doubts about specific treatments you wish to have more information about via e-mail:
The secretary of the Ivo Pitanguy Clinic will get in touch with you to schedule your appointment. If you prefer to schedule your appointment by phone, please call 55-21-2537-5812 Monday to Friday, 8 AM to 6 PM Brazilian time.
© Ivo Pitanguy
Rua Dona Mariana, 65 - Botafogo Rio de Janeiro - RJ Brasil - Cep.: 22280-020
Tel.: (0 XX 21) 2266-9500 Fax: ( XX 21) 2539-0314
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