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Cosmetic Surgery Questionnaire

Personal Information

Gender
Do you have a passport?:

Emergency Contact

Surgery Preferences

The procedure you are requesting or your areas of concern.
For liposuction please state specific area for procedure?
For breast surgery please state your bra size
Choice of breast implants
What results do you expect after surgery?

Medical Conditions

Diabetes / Blood sugar
Arthritis
Ulcers
Anemia
HIV
Emphysema
Unexpected Weight Lossr
Heart problems
Any history of cancer?
*Recent trauma (within 1 year)
Any breathing difficulties?
Any problems with anesthesia?
SURGICAL HISTORY/ Please mention year and procedure

For Women

Do you take any hormones?
Are you pregnant?
Are you currently lactating?
Any medical conditions not mentioned above
Do you have any implants or metal objects in your body?

Medical History

Do you smoke tobacco?
When was your last cigarette or tobacco product?
Do you drink alcohol?
Other Drug Use
List all medications you currently take including dosage
Allergies
Have you had weight loss surgery?

Ever taken an anticoagulent?
Help us better understand your needs. Upload photos of the targeted body part for a precise evaluation and personalized care. Your privacy is our priority.

Med Tourism Co LLC (www.medicaltourismco.com) connects patients to one of the best hospitals in the world. Med Tourism Co LLC does not provide advice on medical treatments nor makes claims or guarantees on the outcome of any medical treatment or surgery. Before making any medical related decision you must thoroughly discuss & seek advice from a qualified medical professional.

The information I have provided is true and accurate and to the best of my knowledge.





*Please review our full disclaimers, Terms & Conditions and, Health Privacy & Confidentiality Statement. Individual results may vary. The statements on this website have not been evaluated by the FDA or any medical professional.

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