Contact - Lewin Ear Reconstruction

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ABOUT
MICROTIA
SURGERY
GALLERY
FAQ
CONFERENCES
INFO

ABOUT
MICROTIA
SURGERY
GALLERY
FAQ
CONFERENCES
INFO

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Facebook Twitter Instagram Youtube

ABOUT
MICROTIA
SURGERY
GALLERY
FAQ
CONFERENCES
INFO

ABOUT
MICROTIA
SURGERY
GALLERY
FAQ
CONFERENCES
INFO

ABOUT
MICROTIA
SURGERY
GALLERY
FAQ
CONFERENCES
- Conferences
- LIVE CHAT
INFO

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Sheryl Lewin, MD, FACS

Office: 310.828.1414
Fax: 310.212.5001
info@lewinmd.com

23430 Hawthorne Blvd.
Suite 120
Torrance, California 90505

FOR MORE INFORMATION ABOUT SURGERY, PLEASE FILL OUT THIS FORM

Patient's Name*
First Last
Patient's Date Of Birth*
MM slash DD slash YYYY
Parent's Name (Use N/A if patient is an adult)*
First Last
Birth Gender*
- Boy
- Girl
------------------------------------------------------------------------
What Is your primary language?*
Email*
Where do you live?*
- I live in the United States
- I do not live in the United States
Which country do you live in?*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
------------------------------------------------------------------------
Has the patient had a previous, unsatisfactory microtia ear reconstruction surgery?*
- Yes
- No
------------------------------------------------------------------------
How did you find us?
Online
- Online
Please pick online source
Family/Friend
- Friend/Family/Medical Professional
Name of Friend/Family/Medical Professional
Microtia/Event
- Microtia Event
Name of event
Other
- Other
Comment
Comments

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Copyright © 2023 Lewin Ear Reconstruction.

All rights reserved.

Website design: Butera Design

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