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. 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.

CONTACT DETAILS

Required fields are marked with an asterisk (*).

{LNG: form [sk]}

Title *---Title---Miss.Mr.Mrs.Ms.

First Name *

Second Name *

House No. and Street

City/Town

Country

Day Phone *

Evening Phone

Email *

Questions/Message *

What is the best time to call you?

 

What would you like to receive from us?

A free online consultation

A Brochure

A Call-Back

 

 

PERSONAL INFORMATION

 

Day--- Select ---12345678910111213141516171819202122232425262728293031

Month--- Select ---123456789101112

Year--- Select ---201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900

Height

Current Weight

Sex

Male

Female

 

 

CHOICE OF SURGICAL PROCEDURE(S)

 

1st Procedure of Interest *---Procedure---Aptos Wire - Nasobial LinesArm LiftBottox - foreheadBreast AugmentationBreast LiftBreast Lift With Breast AugmentationBreast ReductionBrow LiftCheeks Enhancement With ImplantsChin Enhancement With An ImplantDermabrasionEar CorrectionEyelid LiftFace LiftFace Lift incl. Neck LiftGastric Lap BandHair TransplantHyaluronic Acid FillerIVFLaser Removal on Facial AreaLaser ResurfacingLipofullingLiposuctionLypolysisMale Breast ReductionNeck LiftNose SurgeryRhinoplasty - completeRhinoplasty - of the tipScar Treatment By LaserSeptoplastyThigh LiftTummy Tuck - Full Tummy Tuck - Liposuction To SidesTummy Tuck - miniVasectomy

2nd Procedure of Interest---Procedure---Aptos Wire - Nasobial LinesArm LiftBottox - foreheadBreast AugmentationBreast LiftBreast Lift With Breast AugmentationBreast ReductionBrow LiftCheeks Enhancement With ImplantsChin Enhancement With An ImplantDermabrasionEar CorrectionEyelid LiftFace LiftFace Lift incl. Neck LiftGastric Lap BandHair TransplantHyaluronic Acid FillerIVFLaser Removal on Facial AreaLaser ResurfacingLipofullingLiposuctionLypolysisMale Breast ReductionNeck LiftNose SurgeryRhinoplasty - completeRhinoplasty - of the tipScar Treatment By LaserSeptoplastyThigh LiftTummy Tuck - Full Tummy Tuck - Liposuction To SidesTummy Tuck - miniVasectomy

3rd Procedure of Interest---Procedure---Aptos Wire - Nasobial LinesArm LiftBottox - foreheadBreast AugmentationBreast LiftBreast Lift With Breast AugmentationBreast ReductionBrow LiftCheeks Enhancement With ImplantsChin Enhancement With An ImplantDermabrasionEar CorrectionEyelid LiftFace LiftFace Lift incl. Neck LiftGastric Lap BandHair TransplantHyaluronic Acid FillerIVFLaser Removal on Facial AreaLaser ResurfacingLipofullingLiposuctionLypolysisMale Breast ReductionNeck LiftNose SurgeryRhinoplasty - completeRhinoplasty - of the tipScar Treatment By LaserSeptoplastyThigh LiftTummy Tuck - Full Tummy Tuck - Liposuction To SidesTummy Tuck - miniVasectomy

 

 

MEDICAL HISTORY

 

Allergies

YES

NO

Anaemia

YES

NO

Asthma

YES

NO

Contraceptives

YES

NO

Blood pressure

Low

Fine

High

Depression

YES

NO

Diabetes

YES

NO

Drug dependance

YES

NO

Heart problems

YES

NO

Over/Under - active Thyroid

YES

NO

Hormone replacement

YES

NO

Jaundice

YES

NO

Psychiatric illness

YES

NO

 

 

ADDITIONAL INFORMATION

 

Does your religion prohibit you from having a blood transfusion in the event that you will need one?

YES

NO

If you answered 'YES' to any question above please give more details about the condition and medication taken

 

Do you smoke?

YES

NO

If yes, how many?

 

How much alcohol do you drink?

None

Daily

Occasionally

 

Any other condition not mentioned?

Any other medications?

Any local or general anesthetic problems?

Any keloids or bad scarring?

Ever had a blood transfusion?

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

If you have any further questions or requests please supply details

 

 

ATTACH PHOTOS OF THE AREAS YOU WISH TO HAVE TREATED

 

Photo 1

Photo 2

Photo 3

Photo 4

Photo 5

 

I have read the Terms & Conditions