Facial Plastic Surgery Seattle - Sam Naficy, MD - Facelift, Neck lift, Eyelid lift, Brow lift in Seattle, WA

Location

Contact

Our Office

Dr. Naficy

Eyelid & Brow

Cheek & Midface

Face & Neck

Announcement

BOTOX in Seattle

Performed by an experienced facial plastic surgeon, Botox treatments are one of the most effective cosmetic procedures performed in Seattle. This quick and relatively painless procedure can make a real difference in the signs of aging around the eyes. Seattle facial plastic surgeon, Dr. Sam Naficy, is nationally recognized for his experience in advanced techniques of Botox treatment. Read more about Botox

Announcement

THE FEATHERLIFT FACE LIFT TECHNIQUE - Offered by Seattle Facial Plastic Surgeon

See how you can turn back years in just minutes with this non-surgical facelift procedure (also known as Feather lift, Thread lift, Suspension face lift, or Contour lift). Combined with Botox, Restylane, or fat injections, you can get the younger face you want without the down-time of facial plastic surgery. Read more about the Featherlift procedure......

Announcement

WORRIED ABOUT DOWN-TIME?

Seattle, WA - Facelift techniques with minimal recovery.
Healing and recovery time after facial plastic surgery is much less than most people would suspect. The majority of our face lift and neck lift patients need no more than a week before returning to work and social activities, some requiring less than 2-3 days!

Announcement

DR. SAM NAFICY VOTED TOP PLASTIC SURGEON FOR THE FACE

By his medical peers in Seattle for his expertise in facial plastic surgery
Seattle Magazine

Patient Registration

On your first visit, you will need to complete a registration form and a medical history form. For your convenience, you may provide this information by filling out the online version of these forms below. Your information will be emailed to us at our office.

Last Name:

First Name:

Middle Initial:

Mr. Mrs. Miss Ms. Dr.

Date of Birth (mm/dd/yyyy) :

Address:

Street Address
City, State, Zip

Home Phone:

Work Phone:

Cell Phone:

Email:

Patient's Employer:

Patient's Occupation:

Marital Status:
Single Married
Widowed Separated Divorced

Spouse's Name:

Spouse's Employer:

Spouse's Occupation:

Person Responsible for Bill - Insurance Guarantor

Patient's relationship to person responsible for bill:
Self (skip to next section)
Spouse
Child
Dependent

Last Name:

First Name:

Middle Initial:

Address:

Street Address
City, State, Zip

Home Phone:

Work Phone:

Insurance Information

Primary Insurance:

Secondary Insurance:

Emergency Information and Release

In case of an emergency, local friend or relative to be notified
(not living at same address):

Name:

Relationship to Patient:

Home Phone:

Work Phone:

May we contact you to remind you about upcoming or missed appointments?
Yes No

Please provide your preferred contact phone number or email

Would you like to be excluded from mailings and email promotions?
Yes No

If you have any specific cosmetic interests, please check all that may apply:

Surgical:	Non-Surgical:
Rhinoplasty	Botox
Revision Rhinoplasty	Dermatology
Face Lift	Restylane
Mini Face lift	Sculptra
Neck Lift	Radiesse
Mini Neck Lift	Juvederm
Neck Liposuction	Perlane
Nose Reshaping	Artefill
Brow Lift	Fotofacial
Eyelid Lift	Intensive Fotofacial
Cheek Lift	Polaris for Wrinkles & Tightening
Chin Implant	Thermage for Face
Cheek Implant	Thermage for Body
Feather Lift	Thermage for Cellulite
Laser Resurfacing	Treatment of Age Spots/Freckles
Fat Injection	Laser Vein Removal
Lip Augmentation	Laser Hair Removal
Ear Reshaping	Sclerotherapy
Buccal Fat Removal	ToneAbrasion
Skin Cancer	Microdermabrasion
Scar Revision	Retinoic and Glycolic Peel

Please answer the following questions on a scale of 1 to 5:

When looking at my face in the mirror, I believe I look younger, the same as, or older than my true age.

Younger Than		True age		Older Than
1	2	3	4	5

When looking at my face in the mirror, the appearance of my face makes me:

Not Concerned		Somewhat Concerned		Very Concerned
1	2	3	4	5

I am looking for a procedure that can give me a:

Small improvement with minimal down-time		Moderate improvement with some down-time		Significant improvement with longer down-time
1	2	3	4	5

How did you hear about us?
(Check all that apply)

My physician
          (full name)
The yellow pages/telephone book
A friend or family member
          (name)
          May we contact him/her?   Yes    No
          Phone or Email:
Seattle Magazine's TOP DOCTORS
Internet search
          (Google, Yahoo, Other)
Online referral network
          (facialplasticsurgery.net, Other)

Newsletter or mailer
An article or advertisement in

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