COSMEDICS

professional cosmetic enhancement that is affordable

Procedures

Welcome to COSMEDICS

cosmetic surgery - dermatology - gender reassignment surgery - cosmetic dentistry

R e s p o n s e F o r m

Do you have 5 minutes?

Filling out this form is so easy and fast!

Just fill out this form and we will respond to you through email, giving you a package that is personally suited for you. All packages will be estimated in US dollars for uniformity and for convenience.

All information given in this form will be regarded as confidential and will not be divulged to any person.

No time to fill up forms?

You can simply call us by phone, give us your name, contact number and the procedures desired and we will call you back or send you a fax or email of the package at the soonest possible time.

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Please provide the following contact information:

Full Name
e-mail address
FAX
contact no.

Please enter the procedure/procedures desired in the blanks provided:

Procedure/s desired

Do you wish to get the Package of the Month

Yes No

Enter the date when you wish to have the procedure done: (estimated date only)
-- mm/dd/yy
Where do you live?
How long do you plan to stay in Manila/Philippines? (estimate only)
(pls. indicate days or weeks)
Kindly check the other items you wish to add to the basic package:
   hotel accommodations (pick-up to and from the airport included)

   vacation tour

   car rental (w/ chauffer)

   24-hour duty personal nurse
Enter your comments/concerns/inquiries in the space provided below. You may also want to write here some specifics on information we might need for the package to be more personally suited for you.

Are you a "Balikbayan"? (a Filipino residing/working abroad coming back to the Philippines)

Yes No

A better evaluation may be done if you submit pictures of yourself. Strict confidentiality will be followed. Kindly attach your file here. (please see sample pictures on the right)

Expect a response from us within 72 hours. If you do not hear from us after such time, or if this response form malfunctions, please email us at jorgesthetics@yahoo.com or call us (or text/SMS) at +(63918) 9245717 and we will gladly accommodate you.

Sample views for the face: