Medical Professional Guest Referral Application

"*" indicates required fields

Congratulations!!!

Welcome to the world of the many beautiful “Dollz & Queenz” DQ Surgery Bar. You have been chosen by your professional to appear on the show as a guest. This agreement solely is used for purposes to represent your authorization to be a guest of the “Dollz & Queenz” DQ Surgery Bar show. You voluntarily agree to express your own personal views, opinions, and comments in relation to the topic being discussed & only that of the specific area as it relates to your topic. You further agree that you have not been offered monies, been encouraged or advised to express certain answers to the topic being discussed. You further agree that you will provide honest and precise answers to all questions to the best of your ability without bias of race, ethnicity or gender identity as specific thereof.

Please complete & submit the professional guest referral application below:

Name*

First Name Last Name

Name of the professional referring:

Name of the professional(s) business/office/practice whom referred:

Please complete the following statements below if applicable to you. If not applicable place an (N/A) in the blank(s).

What procedure(s) did you have performed? If any?*

What procedure would you like to have performed in the area of cosmetic surgery, bodily enhancements, permanent make-up, dentistry etc. If any? (Please list)*

What is your interest in being a guest on the show?*

Disclaimer:

All photo(s)/image(s) submission(s) are negotiated between that of the Professional and Guest Referral applicant. DQ Surgery Bar DBA “Dollz & Queenz” waive their rights to any determination of which photo(s)/image(s) that the Professional submits for viewing on the show. Note: All photo(s)/image(s) must meet the required guidelines as indicated on the photo release waiver that the Professional submits for review. By signing below, you further agree to the verbal interview, the adaptation of your responses to include the inclusion of your responses and or interviewee that incorporates different answers to multiple interviews.

Printed Name*

Signature*

Date*

Phone

This field is for validation purposes and should be left unchanged.

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"Beyond Just Skin Deep"

At DQ Surgery Bar, we understand that beauty goes deeper than just the skin. We understand how you look impacts how you feel inside, the energy that you project, and the progress of life's daily activities...we always want you to look and feel your best. That is why we have introduced our innovative platform that enables you to talk aesthetics.

Medical Professional Guest Referral Application

Congratulations!!!

Please complete the following statements below if applicable to you. If not applicable place an (N/A) in the blank(s).

Disclaimer:

"The DQ Shop"

“Dollz Tankz”

“DQ Tee’z”

“Body Shaperz”

"Beyond Just Skin Deep"

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