First Name: Date:
Last Name:
Age:
Contact number :
Surgery desired?
How did you hear about us?

Single/Married/Kids?
Height/Weight/Eye?
Occupation?
Hobbies/Interests?

What city do you in?
City:
State:
Zip:
Would family/friends go on tv?
Previous surgery?

Your story:


What do you think makes you a good tv candidate?




IMPORTANT:

We need to see before pictures of your body for the surgery desired.
We also need to see a nice picture of your face so we can see what you look like on camera.

Please email images to: griffinmd@verizon.net

Name your files like this:
myname_b.jpg (for the before picture)
and myname.jpg (for the picture of your face).
Insert your name where it says "myname".

What are the files names of the .jpg pictures that you are sending?


NOTE: Send the information on the form above
by clicking send button below before you send your photos.