We Look Forward to Speaking With You

Contact us to learn more about your options in breast reconstruction.

Patient Inquiry Form

In an effort to best serve you, we request the following information which will be kept strictly confidential. This information will be used to evaluate your individual case, to assist you in navigating and maximizing insurance benefits, and coordinate care as applicable. Although Dr. Levine is an out-of-network specialist for all insurance plans, it may still be possible to access his care.

Contact Us By Phone: 212.245.8140 (M-F 9am – 5pm EST), or leave a message after hours and we’ll be happy to return your call.

Patient Inquiry Form

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General Information

First Name

Last Name

Town

Zipcode

Phone

Preferred Contact Method

Inquiry Type

How Did You Hear About Dr. Levine?

Referring Physician (if applicable):

Insurance Information

Who is your insurance provider?*

Do you have out-of-network benefits?*

Have you consulted with any in-network plastic surgeons for breast reconstruction?*

If yes, who have you seen and what was out the outcome?

Please list all physicians.

Medical Information

Age

Height

Weight

Do you smoke?

Medical History (Breast)*

When were you diagnosed?

History of Radiation*

History of Breast Reconstruction*

History of Mastectomy*

Have you experienced a failure in breast reconstruction?*

When did you experience failure?

Current Breast Surgeon (if applicable)

Do you have any other medical conditions or concerns?

Message

Please tell us more about your unique case, history, and goals in breast reconstruction.

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Name

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REACH OUT TO US

We look forward to connecting with you and providing you with information and answers to your questions about natural tissue breast reconstruction.
Contact Us Today. We Are Here For You.

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Center for Breast Reconstruction

Dr. Joshua L. Levine, MD, FACS

We Look Forward to Speaking With You

Contact us to learn more about your options in breast reconstruction.

Patient Inquiry Form

Patient Inquiry Form

General Information

Insurance Information

Medical Information