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Medical Questionnaire

Please fill in the Medical Questionnaire for your Free Cosmetic Surgery consultation. You will immediately receive an automatic email confirmation. Then reply to the email with some photos of the areas to be treated. The photos should be taken from the front and side.

PLEASE NOTE: It is necessary to provide us with all medication you use for all health problems in order to correctly indicate you to a surgery and allow you to have anaesthesia. In case if false, not complete information or concealed medical history is provided your treatment might be cancelled with no financial refund.

Contact details
(required) (Anti-Spam question)
Your details
Day  Month  Year   (required)
Choice of surgical Procedure(s)
Choice of non-surgical Procedure(s)
Medical History + ALL medication taken
Additional information

Provide the list of ALL medication + supplements you take:

Terms and conditions

Please read the following terms and conditions: