Bosley - Sample 2

Required Fields*

*Salutation:

Mr.Mrs.Ms.

*First Name:

*Last Name:

*Address 1:

Address 2:

*City:

*State:

*Zip Code:

*Email Address:

*Phone:

Alternate Phone:

I would like to schedule a free private consultation.

* The bearer of the gift certificate is entitled to $250 off the price of a Bosley Medical Group hair restoration or eyebrow restoration procedure. Minimum procedure sizes apply (800 Grafts for Hair Restoration procedures; 100 grafts for Eyebrow Restoration procedures). Check expires December 31, 2010. Limit one check per customer per hair transplant or eyebrow restoration procedure. Not redeemable for cash. Not valid with any other offer, coupon or certificate. Not transferable. Void where prohibited. Void if sold, exchanged, transferred or reproduced. Certificate must be presented at time of payment for procedure.

Privacy Statement: The confidentiality of the medical records of all Bosley patients has been and continues to be strictly protected. We release medical information regarding one of our patients whenever the patient instructs us to do so, or whenever we are required to do so by legal process. Professional services are provided by the licensed physicians of Bosley Medical Group, L, Lee Bosley, M.D., founder