Mirzai Plastic Surgery and Medical Aesthetics
Todd Mirzai
The Beauty of Precision

Appointment Request

*PLEASE BE ADVISED THAT WE ARE EXPERIENCING TECHNICAL ISSUES WITH OUR APPOINTMENT REQUESTS VIA OUR EMAIL OPTION.  PLEASE CALL OUR OFFICES ON THE ISLAND YOU WISH TO BE SEEN AT DIRECTLY AND WE WILL BE ABLE TO ASSIST YOU.   

The first step towards a beautiful, healthy look is to schedule an appointment. Please contact our office by phone or complete the appointment request form below. Please specify on which island you would like to request your appointment.  Our scheduling coordinator will contact you to confirm your appointment.

Please do not use this form to cancel or change an existing appointment. Please call our office directly.

A credit card maybe required to reserve your time slot. We reserve the right to charge patients for the full cost of a service/consult if they cancel within 72 hours of their appointment.

A 50% NON REFUNDABLE booking fee/deposit is due at the time of booking Ultherapy treatments.

25% NON REFUNDABLE booking fee/ deposit is due at the time surgeries or in-office procedures are scheduled.

*Items in bold are required.
Are you a current patient?


Which office location(s) would you prefer for your appointment?


Preferred day(s) of the week for an appointment?

Preferred time(s) for an appointment?

Please describe the nature of your appointment (e.g., consultation, check-up, etc.):

Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.

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