REQUEST A QUOTE

Welcome and thank you for your interest in our services! In order to provide you with a formal quote, an evaluation of your case is required. Please fill out this document with complete information so the doctor can better assess your case.

Medical History:

Please fill out this form and send photos with the following specifications to: andres@galvezmd.com. Without clothes/underwear, please take 100% visible pictures of the areas you would like to assess. Take the pictures in the following way: (I) frontal, (II) back, (III) lateral (bending forward – photo taken from the side), (IV) oblique (left and right half profile of the area to assess) and (V) in flex position (with arms lifted). a. from the neck to your knees - if interested in body procedures; or b. from the top of your head to your shoulders - if interested in facial procedures.