1. Your Contact Details

Name

Address

Country

Email

Phone Number

2. Family Doctor Contact Details

Name

Company / Practise Name

Address

Country

Phone Number

3. What is your height in feet and inches?

4. What is your current weight?

5. What is your gender?

FemaleMale

6. What surgical procedures would you like?

Pick one from the list.

---Aesthetic surgery?Reconstruction?Hand/Wrist/Elbow?Other?

7. Is this a medical vacation?

YesNo

8. Has any family member suffered from any of the following ailments?

Please select all that apply.

Bleeding DisorderHeart DiseaseHigh CholesterolHypertensionType 1 DiabetesType 2 DiabetesNone of my family members suffers from any of these ailmentsPrefer not to answer

9. Do you suffer from any of the following ailments?

Please select all that apply.

Adrenal InsufficiencyAllergiesBleeding DisorderDeep-vein ThrombsisDiabetesHeart DiseaseHepatitis BHepatitis CHIVHypertensionHyperthyroidismHypothyroidismKeloidHave you ever had a cardiac arrest?Are you currently on medication?Do you drink alcohol?Do you smoke cigarettes?Are you pregnant?Do you plan to have children?Are you breast feeding?Do you plan to breast feed?I do not suffer from any of these ailmentsPrefer not to answer

10. If you have had a keloid please state where on your body and attach a picture of it.

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