Contact Dr. Spence

Orlando Office

130 Hillcrest St.
Orlando, Florida 32801
Phone: 407-999-2585
Fax: 407-999-2628

Toll Free: 877-577-3623 (877-5SPENCE)

Please complete this form so we may contact you with regards to the comments you place in the form below. If you would like to schedule a consultation with Dr. Spence, indicate this in your remarks so we may have our office coordinator contact you to secure an appointment.

The information requested on this contact sheet will assist us in meeting your needs. It is the goal of our team to understand your surgical expectations, your time frame for surgery, and your general medical conditions. Do take a few moments to answer these very important questions and we look forward to welcoming you to our practice.

Please complete every field.

PERSONAL PROFILE
First Name:		Last Name:
E-mail:		Phone Number:
Best way to reach you: Email Phone
Best time to call/contact: Morning Mid-day Afternoon Evening Other:
Mailing Address:		City:
State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands US Washington West Virginia Wisconsin Wyoming		Zip:	Country:
Do you smoke? Yes No		Sex: Female Male
Birth Date (mm/dd/yyyy):		Height:	Weight:
PROCEDURE INTEREST & HISTORY
Main Procedure Interest:	-- Choose a procedure -- Breast Augmentation Breast Lift Breast Reduction Breast Implant Revision Gynecomastia Brow Lift Eyelid Rejuvenation Face Lift Nose & Ears Abdominoplasty (tummy tuck) Body Lift Brachioplasty (arm lift) Liposculpture BOTOX®, Fat, Collagen Injections Chemical Peels Lasers Microdermabrasion Skin Care Products
Other procedures:		Budget: -- Choose One -- UNDER $1,000 $1,000 - $3,000 $3,000 - $5,000 $5,000 - $10,000 $10,000+
Financial Assistance Required:	Yes No	Timeframe for surgery:	-- Choose a timeframe -- Within a month 1 to 3 months 3 to 6 months 6 months to a year Not sure
Have you had plastic surgery before?	Yes No	List previous surgeries or major illness and dates:

OTHER
How did you hear about Dr. Spence?
Questions/Comments:
Check here to join our mailing list.
Privacy I have read and understand the Privacy Policy.
Terms of Use By checking this box you agree to the Terms of Use listed here: Communications through our website or via email are not encrypted. Use of the Internet or email is for your convenience only. By checking this box you hereby agree to hold Dr. Kenrick Spence, his doctors and affiliates, harmless from any unauthorized uses of your information by outside parties.