Medical History Form

Important Note: Medical History Form is a very important tool to assess your physical availability for the intended procedure. The Information provided is evaluated by our plastic surgeon who is assessing your pictures as well.

Please enable JavaScript in your browser to complete this form.
example 01/01/1900
Multiple Choice
Contact Person in case of emergency
Phone number including country code
Do/Did any of these Medical Problems apply to you? (Please select)
Do you have any food limitations or food allergy?
Do you smoke?
Do you drink alcohol
Did you have any surgery before?
Do you have any disease that you consider as important to declare?