Official Website of Dr. Ghaisari

NEWLETTER

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CONTACT

Clinic Address:
Unit 4, Ferdous Tower, Bagh Ferdous, Vali Asr Ave, Tehran-iran.

Website: www.drghaisari.com
E-Mail: drghaisari@drghaisari.com

Hospital Address:
LALEH HOSPITAL
Sima Iran St., Phase 5, West Town
Tel: (+9821) - 22706595
Fax: (+9821) - 22706596

Contact me by (check all that apply):
E-Mail	Phone

I have been considering a procedure (check only one):
Less than one month.	Between one & six months.
Longer than six months.

Contact information:

First name:*

Last name:*

Sex:

male

Female

D.O.B.:

Month:

Day:

Year:

Address:

City:

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Best phone # to reach you:*

Best time to call: *

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E-mail: *

Procedure(s) of interest:

If you are interested in a personal consultation, please call our office to set up an appointment with Dr. Ghaisari, our patient care coordinator at (+9821) - 22706595.

When? (check only one)

	I'm likely to have this procedure sometime in the next year.
	I'd really like to get this done in the next 4 months.
	I'd consider coming in for a personal consultation.
	I'd like to set up a consultation soon.

Comment/Question:

If you have photos of yourself that you would like to send us, please use the upload buttons below to upload photos:

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Please list any previous surgeries:

Thank You!