Birmingham Aesthetic Academy Application

Step 1 of 7

Personal Information

First Name(Required)

Last Name(Required)

Phone(Required)

Email(Required)

Date of Birth(Required)

Residential Address

Street Address City State ZIP Code

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Are you ready to take the first step toward a more confident you? Contact our office today to schedule a consultation appointment with Board-Certified Cosmetic Surgeon, Dr. Rifai.

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Birmingham Aesthetic Academy Application

Personal Information

Medical Professional Credentials

Medical Experience

Dietary Preferences for Breakfast and Lunch

Emergency Contact Information

Photo ID Requirement

Additional Information

Ready to Get Started?

SCHEDULE YOUR CONSULTATION TODAY!