Plastic Surgery

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First Name *

Last Name *

Email *

Phone *

Date of birth (DD_MM_YYYY)

Gender

Male

Female

Other

Height (cm)

Weight (Kg)

Desired Results

Previous Surgery

Yes

No

Previous Surgery Details

Health Issues

Yes

No

Health Issues Details

Current Medications

Medication and dosage

Have you ever had a Stroke or Transient Ischaemic Attack (TIA)?

Yes

No

Have you been hospitalised, had surgery or received medical care within the past 5 years (including cosmetic surgery)?

Do you have implants or metal objects in your body? Please specify

Do you have difficulty with healing or scarring?

Yes

No

Do you have any allergies to food, drugs etc?

List all vitamins or food/nutritional supplements you currently take and dosage.

Have you ever taken a MAO inhibitor such as Nardil, Marplan or Parnate?

Yes

No

Have you ever taken daily Coumadin, daily Heparin or daily Aspirin?

Yes

No

Do you Smoke or Vape?

Yes

No

Do You Drink Alcohol?

Yes

No

Please upload photos