initial medical interview – Coramed Beauty Surgery

Contact: clinic@coramed.uk / +44 7704 477053

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BREAST SURGERIES

Pre-qualification form

Please fill out this form to quickly find out whether you qualify for the treatment and what its cost will be.
Thank you!

First Name

Surname

Date of birth

Male

Height

Weight

Passport No. / ID.No.

Email

Phone number

Any previous operation?

Did you have plastic surgery?

Anaesthesia Problems

Anaesthesia Problems in Your family?

Allergies

Herbal preparations or aromatherapy?

Current medication

Bad habits

Do You smoke?

Yes No

Do You drink alcohol?

Yes No

Do You suffer for (mark as many as necessary):

Blood pressure - High Blood pressure - Low Blood Disorders - Haemophilia / Septicaemia History of Bleeding, coagulations or clotting disorders Heart disorders: Angina, Coronary, Congenital, Thrombosis, Fever, RH Diabetes Kidney / bladder related conditions Liver conditions, jaundice Ulcers (gastric, duodenal), diarrhoea, hiatus hernia Asthma, TB, bronchitis, lung disease Varicose veins, thrombosis of veins Porphyria (patient or members of family) Epilepsy, any other muscular or neurological disorder Light stimulated diseases - Lupus. Solar urticaria Orthopaedic condition Excess bleeding post-surgery or injury Do you use anti-coagulants Any recent minor, illnesses Skin Diseases / Skin disorders (Eczema, Psoriasis, Dermatisis, cancer etc) Skin pigmentary conditions [hyperpigmentation, moles, etc) History of Keloid Scarring Hormonal Disturbances - Thyroid problems, etc Disability of any kind Have you taken any antibiotics within the last 6 month Do you have any semi-permanent make-up Have you been tested/diagnosed with HIV/Aids Have you been diagnosed as having Hep A, B or C?

Please state what blood group you are.

If you have answered YES to any of the above medical conditions

Have you ever been diagnosed with tuberculosis, sexually transmitted diseases, hepatitis B, HIV/AIDS, tropical malaria or other infections? If so, please provide details including dates and results of any treatments. Please ignore infections such as colds and flu.

YES NO

Breasts surgeries

Breast augmentation Breast lift Other

When was your last pregnancy? exact date of the delivery?

How many times you was pregnant?

Did you lost some weight, if yes how many stones?

What is your actual size of bra?

What size do you want to have?

What would you like to change? Please describe your expectations?

Pictures of area that you want to improve

Who is your coordinator?

Anna Danielska Lilianna Patron Urvi Chhatrala

I agree to the use of my personal data sent in the form in order to include them in medical documentation, prepare an offer and for marketing purposes.

Are you having trouble filling out the form?

Anna Danielska

+44 7704 477053
+48 519077919 (WhatsApp)

Lilianna Patron

+44 7704 477053
+48 519077919 (WhatsApp)

Urvi Chhatrala

+44 7930 725520
+48519077911 (WhatsApp)

Location

UK Office:

UK Medical Treatment Abroad Ltd
24 Astor Court, Ham View
CROYDON, CR0 7XA

Legal informations

PRIVACY POLICY
DEPOSIT POLICY OF CORAMED CLINIC
CANCELLATION POLICY

© 2019 The service and copy rights
of UK Medical Treatment Abroad Ltd.

Contact our customer support

Urvi Chhatrala +44 7930 725520
+48519077911 (WhatsApp)

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