Rhinoplasty Seattle - Sam Naficy, MD - Seattle Rhinoplasty Nose Plastic Surgery Nose Job

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Dr. Naficy

Rhinoplasty

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Announcement

CASE OF THE MONTH

Seattle rhinoplasty surgeon Sam Naficy, MD performed this rhinoplasty procedure to help refine the tip and reduce the hump on the bridge of the nose. The patient also had a deviated septum which was corrected at the same time as the rhinoplasty.

See the before and after results here

Announcement

ARE YOU INTERESTED IN SEEING WHAT YOUR NOSE COULD LOOK LIKE AFTER A RHINOPLASTY?

Seattle rhinoplasty surgeon Dr. Sam Naficy can perform computer simulations to help you visualize the potential outcome of rhinoplasty. Check out this link for more details about rhinoplasty simulations. Also, if you are wondering whether you would be a good candidate for rhinoplasty, you may submit your photographs to us for a virtual consultation.

Announcement

DR. SAM NAFICY VOTED TOP SEATTLE PLASTIC SURGEON FOR THE FACE

Voted by his medical peers for his expertise in rhinoplasty and facial cosmetic 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:
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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
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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:

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Work Phone:

May we contact you to remind you about upcoming or missed appointments?
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Please provide your preferred contact phone number or email

Would you like to be excluded from mailings and email promotions?
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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
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