Patient Appreciation Registration Form

Dr. Monica Tadros has organized the Patient Appreciation program as a service to her patients to communicate directly with all those interested in receiving information on advances, new technology and promotions (for minimally invasive and aesthetic services where applicable). The program is voluntary and open to all persons who wish to register and/or receive a membership card.

Please fill out to information below to register your membership card.

*= Required information

Contact Information
First Name* First Name Required		Last Name* Last Name Required

Address* Address required
City* City Required	State* State Required	Zip Code* Zipcode Required
Country* City Required
Phone* Phone Required
Email* Email RequiredInvalid Email Format

Patient Appreciation Card

Bar Code* Bar Code Required

Promotion Code (Optional)

I would like to receive additional information on advances, new technology and promotions (where applicable) in the following areas of interest (check all that apply):

MINIMALLY INVASIVE
	Botox®	Eyelash Growth (Latisse®)
	Facial Fillers (Restylane®, Juvederm®, Perlane®, Radiesse®)	Skin Resurfacing: Lasers, Dermabrasion, Chemical Peels
	Fat Grafting and Stem Cell Augmentation

FORM
	Rhinoplasty	Ethnic Rhinoplasty
	Revision Rhinoplasty	Rhytidectomy (Face-lift)
	Eyelid, Forehead and Eyebrow Lift	Facial Contouring
	Lip Shaping	Otoplasty (Ear-tuck)

FUNCTION
	Disorders of Nasal Breathing & Deviated Septum	Sinus Disorders
	Bell’s Palsy, Facial Paralysis Treatment & Nerve Rehabilitation	Sleep Apnea

RESTORATION
	Congenital Deformities, Facial & Nasal Cysts, Asymmetry & Mal-development	Tumor Resection/Repair of MOHS Defects: (face, eyelids, lips, ears, nose)
	Cranioplasty (Skull Restoration)	Facial & Nasal Fractures
	Lipodystrophy	Scar Revision

Terms & Conditions

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Patient Appreciation Registration Form

Contact Information

Patient Appreciation Card