Medical Questionnaire

Information enclosed in Medical Questionnaire and your photos are essential in order to enable our surgeons to see your problem and make a proper assessment. They will analyse the treatment you require and make a suggestion of what would be the best way to reach the best result for you.

Do not hesitate and fill in our Medical Questionnaire and submit it along with your photos of a particular area you wish to have treated. The best aspects for the photos are from the front and side. Once we receive them we will be able to provide you with the medical assessment within 24 - 48 hours. At the same time we´ll give you the exact price of your treatment including accommodation.

We can assure you that our prices are accurate and hide no extra charges.

Are you interested only in an approximate price of your treatment and do you not intent to send us your photos? Get the estimated but maximal quote today by simply filling out of our Contact formular.

PERSONAL DETAILS

Your personal details are used for purposes of a record, in accordance with GDPR. Our surgeons also require some of your personal information for preparation of an accurate assessment.

Name *

Surname *

Email *

Phone *

Select title *

Sex *

Date of birth D/M/Y

Weight

Height

Considered date of surgery

Street, House No, Town/City

Country

CHOICE OF SURGICAL PROCEDURE(S)

Please, feel free to list the desired procedures. Our surgeons will advise you whether the requested surgeries can be combined and/or undergone at same time.

1st Procedure of treatment *

2nd Procedure of treatment

3rd Procedure of treatment

MEDICAL HISTORY

Information about your current medical condition and your medical history must be filled out accurately. In order for our surgeons to provide you with a conscientious assessment and advice on possible drug interaction or contraindicated illness, they have to take into consideration the medical background as well.

ADDITIONAL INFORMATION

Additional information about your lifestyle, possible past or present medical issues and your aspirations will enable our surgeons to advise you on, whether you have chosen the right procedure and advice on any issues in preparation for the surgery, if necessary. If you answered yes to any of the above listed medical conditions or diseases, where applicable, please, specify the severity of the condition and the type of treatment received, together with medication used.

Other diseases or medical conditions you have suffered or suffer from.

If you are taking other medication or nutritional supplements, please, list below.

Have you undergone any surgery previously?

If you have experienced any postoperative complications, please, specify below.

Does your religion prohibit you from having a blood transfusion, in case that you would need one?

Do you have any experience with/after general anaesthesia?

Have any of your family members experienced problems with/after general anaesthesia?

Do you smoke? If yes, how many cigarettes per day?

Describe your personal desires and aspirations for the outcome of your procedure(s).

If you have any further questions or requests, please, supply the details.

Attach photos of the areas you wish to have treated

from the front and the side,
for the nose surgery from the bottom as well,
against a white background,
in a good light,
from a distance that will allow the surgeon to see the problem area clearly.

Images of the areas

Discount unique code

Please fill in the unique code which you have obtained

Unique code

We would like to inform you, that processing of your personal data is necessary in order for us to have a contract with you. Here you can find more information about Processing of personal data.

* I hereby give consent according to article 6.1 (f) Regulation GDPR and paragraph 13 1 (a) act no. 18/2018 with regard to the protection of personal data, processing and storing of my personal data to New Look Holiday, for the communication purposes. I give my consent to my personal data in extent of: name and surname, email address and phone number.

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I agree to receive offered news, discounts, bonuses and other benefits

WHY TO CHOOSE US FOR COSMETIC SURGERY ABROAD

New Look Holiday is proud to have many satisfied clients from all over the world.
Our goal is to leave each and every client with the best impression and meet his or her expectations or even go further.