Dr Sanan Patient Form Submissions

Thank you for your interest in consulting with Dr. Sanan for your face, neck, & nose rejuvenation. To begin, please fill out the form below. Following submission, Dr. Sanan’s patient care coordinator, Arianna, will be in touch with you to discuss the next steps.

Dr. Sanan’s consultation fee is $200, no matter the procedure you are considering. All surgical pricing is customized based on Dr. Sanan’s unique recommendations for you. Please note that Dr. Sanan does not accept any insurance. For more detailed information on Dr. Sanan’s pricing structure, please go to the specific procedure FAQ section.

For anesthesia safety, our maximum BMI is 30. You may calculate your BMI here: https://www.nhlbi.nih.gov/calculate-your-bmi. If your BMI is over 30, or you plan on losing more than 15 pounds to reach a personal goal weight, please wait until you have achieved those goals prior to submitting a consultation inquiry.
Name*

First NameLast Name
Date of Birth*
Sex
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Height (in ft) *
Weight (in lbs)*
BMI*
Procedure of Interest: Please choose all that apply.*

Full Facial RejuvenationDeep Plane Face LiftDeep Plane Neck LiftUltrasonic Piezo RhinoplastyLip LiftUpper BlepharoplastyLower BlepharoplastyEndoscopic Brow LiftBrow Reset
When are you interested in having surgery?*
Are you currently taking a GLP-1 medication (Ozempic, Wegovy, Zepbound, Mounjaro, etc)?*

YesNo
What medical conditions do you have?*
What medications do you take?*
What surgeries have you had (both cosmetic or functional)? Please also list the year you had the procedure. *
Do you smoke tobacco?*

YesNo
Have you ever smoked tobacco?*

YesNo
Do you have sleep apnea? If so, please elaborate on your diagnosis and treatment plan*
What treatments have you had performed on your face or neck? Please choose all that apply.*

Neuromodulators (Botox, Dysport, Daxxify, etc.)Hyaluronic Acid Filler (Restylane, Juvederm, RHA, Revanesse, Evolus)SculptraRadiesseUltherapyThermageThreadliftFraxel or CO2 LaserRF Microneedling (e.g. Morpheus 8)Laser Treatment for Facial CapillariesNone
If you checked any of the above boxes off, please elaborate on when your most recent treatments were and any other notes that we should be aware of.*
Prior to your consultation, Dr. Sanan will review your photos so we can best assist you and answer any of your questions. Please upload high-quality digital photos of your face and neck to complete your consultation inquiry form. Please find a room with natural light and a neutral background and have someone help photograph you (no selfies!) from a few feet away. The camera lens should be at eye level, and your chin should be parallel to the floor. Please ensure that your entire face and neck are within the frame. If you wear glasses, please remove them for the photos.
Right side profile:*

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Front View:*

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Left side profile:*

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Disclaimer: Please note, communications through our website or via email are not encrypted and are not necessarily secure. By submitting this form, you are granting Dr. Sanan Facial Plastic Surgery permission to review your photos. These photos will only be used in-house for consultation purposes.*

Agree
Thank you for taking the time to provide this information. Dr. Sanan and his team put so much care and attention into every patient throughout their individualized surgical journeys. We look forward to communicating with you & are excited to begin working with you!

Please allow for 48-72 hours of processing after successful form submission.
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