First Name *
Last Name *
Email Address *
Phone # *
I am a * Please SelectNew PatientExisting PatientHealthcare ProviderVendorOther
Treatment * Please SelectBotoxDermal FillersHormone ReplacementUrinary IncontinenceOther
Subject * Please SelectRequest AppointmentChange AppointmentPre-procedure QuestionAftercareGeneral QuestionBilling/PaymentsOther
8 + 0 = ?Please prove that you are human by solving the equation *
* For your security & HIPAA compliance please do not submit privileged, confidential and/or protected health information via form.
1375 Flushing Rd.
Flushing, MI 48433
MONDAY – THURSDAY
8:00 pm to 5:00 pm
8:00 am to 11:45 am
SATURDAY & SUNDAY