Breast Surgery

Body surgery

Facial surgery

Intimate surgery

Specialy for men

Hair transplants

Aesthetic medicine

NEWSLETTER

Subscribe to our newsletter

PRO SPACE

CUSTOMER SPACE

Free Quote

To allow the surgeon to establish an accurate diagnosis, we would appreciate it if you would fill in the following form:
We confirm that all information submitted remains strictly confidential and at the disposition of the surgeon only.

	Mr. Mrs. Miss.
Surname: *
Forename: *
Date of birth:
Address:
City:
Post code:
Country:
Nearest airoport:
Profession:
Phone:
Mobile:
E-mail: *

Intervention 1
Other intervention 2
Other intervention 3
Other intervention 4
Other intervention 5

Upload pictures
To obtain a personalized estimate of the surgeon with the diagnosis, evaluation and medical information , please do send your pictures to the following email address: customercare@surgery-and-holiday.com NB! For the Interventions of breast, nose and face, a photo of the front side and bottom to topwould be perfect For the Interventions of the whole body a photo of the body front, side and rear.
Have webcam ?	Yes No

Stay
Choose:
Board:
Type of room:
Visit period:
Excursion/Leisure:
Number of persons:
Number of adults:
Children 2-12:
Children 0-2:

Personal information
Your size:	cm
Your current weight:	kg
What is the maximum weight you have reached ?	kg
what is your dress size: Chest
Waist
Do you smoke ?	Yes No
How many cigarettes a day ?	per day
When did you start smoking ?	year
Have you stopped smoking ?	Yes No
Since when ?
Do you drink alcohol ?	Yes No
How often ?

Medical history
Are you currently taking any medications ?	Yes No
what are they ?
Are you currently under any treatment ?	Yes No
Since when ?
Do you have any allergies ?	Yes No
what are they ?
Are you allergic to any medicines ?	Yes No
Which one ?
Others ?
Do you have diabetes ?	Yes No
Do you suffer from cholesterol ?	Yes No
Do you suffer from high blood pressure ?	Yes No
Do you suffer from anaemia ?	Yes No
Do you suffer from a blood condition ?	Yes No
Have you gone through depression ?	Yes No
Are you currently depressed ?	Yes No
Are you reaches viral diseases ?	Yes No
Which are they ?
Are you treated by a psychiatrist or a psychologist?	Yes No
Have you explained the intention to perform such an operation ?	Yes No
Have you ever had problems with blood flow or venous insufficiency during your trip air ?	Yes No
Have you used drugs or other substances in the past or recently ?	Yes No
Do you have any problems with hypertension ?	Yes No
What are the medicines you take as a remedy ?
Do you have heart problems ?	Yes No
Do you use birth control pills or hormone therapy?	Yes No
Are you diabetic ?	Yes No
In your family, there have been cases of problems with anesthesia ?	Yes No
Suffering from asthma ?	Yes No
Posted courtesy of your medical history:

Surgical record
Have you had surgical procedures before ?	Yes No
Which ones ?
Have you had cosmetic surgery ?	Yes No
Which part of your body ?

Gynecological and obstetrical record (For women)
Number of pregnancies ?
Number of children ?
Number of caesareans ?
Do you intend becoming pregnant ?	Yes No
When ?

In case of breast surgery
What is your cup size ?
Have you had mammography ?	Yes No
When ?
What was the outcome ?
Have you had breast cancer before ?	Yes No
Have you had history of breast cancer in the family ?	Yes No
which member of the family ?

Motivations
Since when have you wished for cosmetic surgery ?
Why do you want to go through surgery ?
Have you already consulted a plastic surgeon ?	Yes No
For which type of operation ?
How did you hear about our company? By:
Comments
Thank you for your interest. Find out as follows: target prices for each procedure and conditions are available at www.surgery-and-holiday.com To create a personalized and precise, it is necessary that you send pictures frontal and profile of the area for which intervention is necessary If rhinoplasty or breast is also need a photo taken from the bottom up and from behind the Liposuction, which completes the form on medical history the budget to be free. Thank you for your confidence in us to send regards Customer Service

Breast Surgery

Body surgery

Facial surgery

Intimate surgery

Specialy for men

Hair transplants

Aesthetic medicine

Free Quote

Upload pictures

Stay

Personal information

Medical history

Surgical record

Gynecological and obstetrical record (For women)

In case of breast surgery

Motivations