The Long Island Center
Appointment Request
(Fields marked with an asterisk are mandatory)

*Name:

*Address:

*City:


*State: *Zip:

*Home Phone: -

Work Phone: -

Fax: -

E-mail address:

*What type of appointment would you like to schedule?

Hair Removal Consultation Hair Removal Treatment Vein Removal Consultation Vein Removal Treatment Cellulite Reduction Consultation Cellulite Reduction Treatment Epifacial™ Consultation Epifacial™ Treatment

*What date would you like to request?

1st Choice:
2nd Choice:

I would prefer a morning appointment an afternoon appointment.

*Are you currently a patient of the Long Island Center for Hair, Vein & Cellulite Removal?
Yes No

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