Contact Us

Contact Details

(03) 9923 2721

reception@jeremyrichardson.com.au

Address & Business hours

416 Queens Parade, Fitzroy North, VIC 3068
Monday – Friday: 8:30am to 5pm

Enquiries

You can save your enquiry and come back to it at any time. Scroll to the bottom of the form and click “Save and complete later”

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Phone

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First Name*

Last Name*

DOB*

Title*

Gender*

Email*

Please double-check your email address or we may not be able to contact you!

Phone*

Please let us know the type of procedure(s) you are interested in:*

Please choose the most appropriate answer from this list. If you are interested in multiple procedures (E.g. Browlift AND Rhinoplasty) let us know below.

Any additional information?*

Tell us more about the operation(s) you are interested in. If you are interested in combined procedures (E.g. Facelift WITH Facial Fat Grafting) please let us know.

What are you hoping to achieve with surgery?*

When would you like to have surgery?*

Have you had any previous cosmetic surgery?*

Yes

List surgery and date*

Please tell us about yourself:

Height (in meters E.g. 1.65)*

Please ensure you have entered your height in metres, NOT in centimetres.

Weight*

BMI Calculation

Do you currently smoke, or vape?*

Yes, daily

Sometimes, socially

No, never

All patients MUST be nicotine free before we will allow surgery to be booked. This includes nicotine replacement therapy such as gum or lozenges.

Referral

A referral must be provided by your GP or a referring specialist prior to a consultation.

If you already have your referral, you can upload it here. Please ensure the referral is either a .jpg image or a .pdf document.

Your Referral:

Max. file size: 1 GB.

Your enquiry can still be submitted if you do not yet have a referral. Please note that a referral does not automatically entitle you to a Medicare rebate for your consultation.

How did you hear about us?*

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