2601 Princess Anne Street, Suite 201
Fredericksburg, Virginia 22401
phone 540.371.7372 fax 540.371.3002

Schedule a Consultation with Dr. Shane Palmer

Please provide the request information below to begin the process. A representative of Vein & Laser of Fredericksburg will be in contact with you to schedule your consultation date and time. Asterisks denote required fields (*) .


Preferred Day of Week: (check all that apply)	Monday Tuesday Wednesday	Thursday Friday
Preferred Time of Day: We are open M-F from 9 am - 5 pm	Morning Afternoon No Preference
Reason for Consultation: (check all that apply)	Vein Treatment Laser Lipolysis Photofacial and/or Skin Tightening Microdermabrasion Hair Removal BOTOX® or other Dermal Fillers
Have you received treatment for the above marked services in the past?	Yes No
If yes, please list where, when, doctor's name and any other details you think that we should know about:
Your Name:	*
E-mail Address:	*
E-mail (again to confirm)	*
Phone:	*
Address:
City:
State: Zip:
Reason for inquiry:	Medical Cosmetic Both
Questions / Comments:

Spam Check:	* Please type the numbers 7, 1, and 1 in the field above using no commas and no spaces.

Hours of Operation: Monday though Friday from 9:00am-5:00pm