Extreme Makeover Registration Form

Instructions: Please print this form, fill it out, and send it to:

Extreme Makeover
Cosmetic Surgery and Laser Center
Rockwood Tower
Hyde Park, Ohio 45209

Please Fax this Registration Form to 513.396.8995.

Call 513.351.FACE (3223) for questions.

Email questions to info@351FACE.com

IMPORTANT! You MUST include a photo of yourself!

Name:________________________________

Email:________________________________

Phone:_______________________________

Why do you want an extreme makeover? (use additional sheets if necc.)

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