Full Name (As Appears On Your Passport) *
First Name
Middle Name
Last Name
Birth Date *
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Mobile Number *
E-mail *
Current Address *
Gender *
Nationality *
Preferred Language *
Full Name *
First Name
Last Name
Relation To You *
Mobile Number *
E-mail *
Current Address
What Procedures Do You Require? You may select more than one. *
Arm Lift
Breast Augmentation
Breast Lift
Breast Reduction
Breast Revision
Buttocks Lift
Eyelid Surgery
Nipple Lift
Face Lift
Inverted Nipple Correction
Labiaplasty
LASIK Eye Surgery
Liposuction
Male Breast Reduction
Prominent Ear Correction
Rhinoplasty (Nose Surgery)
Tummy Tuck
Thigh Lift
Other (Please specify in next box)
What Results Do You Want To Achieve? *
Surgery Date (If Known)
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Fly Home Date (If Known)
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Have you previously had cosmetic surgery?
*
If yes, please give details including year.
Do You Have Any Of The Following:
Diabetes or blood sugar problems?
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Thyroid problems?
*
Heart problems?
*
Lung problems?
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Blood pressure problems?
*
Kidney or liver problems?
*
Blood disorders?
*
Previous/current history of cancer?
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HIV or AIDS?
*
Nervous breakdowns/Depression?
*
Neurologic problems?
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Anaesthesia problems?
*
Do you suffer from sleep Apnoea? (Breathing stops for a period of time during sleep)
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Have you ever had a Stroke or Transient Ischaemic Attack (TIA)?
*
If you have answered YES to any of the above, please provide details (including medication and dosage taken)
Have you have had any medical conditions not mentioned above? If "Yes" please specify
*
Are You Female And Requiring Breast Surgery and/or Tummy Tuck Surgery? IF YOU ANSWERED NO, PLEASE GO TO THE NEXT PAGE.
*
Are You Currently Pregnant?
*
Have You Undergone Any Surgical Means Of Birth Control? E.g. Tubal Ligation
*
How Many Children Have You Given Birth To?
*
How Old Is Your Youngest Child?
Are You Planning Any More Pregnancies?
When Did You Last Deliver A Baby?
When Did You Last Breast Feed?
Do Your Breasts Still Have Milk At This Time?
Do You Take Birth Control Pills, Hormone Replacement Medication Or Wear A Hormone Patch?
*
If "Yes" please specify
*
Have you been hospitalized, had surgery or received medical care within the past 3 years (including cosmetic surgery)?
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Do you have implants or metal objects in your body? IF YES, PLEASE GIVE DETAILS
*
Do you have difficulty with healing or scarring? IF YES, PLEASE GIVE DETAILS
*
Do you have any allergies to food, drugs etc? IF YES, PLEASE GIVE DETAILS
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List all medications you currently take and dosage you take for each.
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List all vitamins or food/nutritional supplements you currently take and dosage.
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Have you ever taken a MAO inhibitor such as Nardil, Marplan or Parnate?
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Have you ever taken Coumadin, Heparin or daily Aspirin?
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Do You Smoke?
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If You Answered YES, How Many Cigarettes Do You Smoke Per Day?
Do You Drink Alcohol?
*
If You Answered YES, How Many Alcoholic Beverages Do You Consume Per Week?
Your photos are an important part of your free assessment from the Surgeon. Please follow the Photo Guidelines. If you have trouble uploading photos with this form, please email them direct to your consultant or enquiries@medimakeovers.com .
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Is there any other information that you would like to share with us?
I declare that I have truthfully completed the entirety of this form and that I have not made any purposeful omissions.
*
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