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* Before and after the surgery photos are just for example.
Depending on the individual, the result of surgery may vary.

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Telephone Consult

  • Consult Items*
    (can multi-select)

                     
               
            

    Name*
    Age*
    Sex*   
    E-mail*
    E-mail
    (reconfirm)*
    Phone Number*
    Want to Telephone
    Consult’s Time*
    Year Month Day Time Minute