First Name
Surname
Date of birth
Passport No. / ID.No.
Email
Phone number
Height
Weight
Have you ever had operation?
Did you have plastic surgery?
Have you had any problems during anesthesia or after waking up?
Do you know if any of your close relatives had any problem during anesthesia?
Do you suffer any allergies
Do you use any herbal or aromatherapy?
Current medication: have you been taking recently any medication or diet supplements
Do you take steroids?
When last time you went to the doctor for any examination
Have you had any blood test within last 2 years?
Do You smoke?
Do You drink alcohol?
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
When was your last pregnancy?
How many times you was pregnant?
Did you lost some weight?
What is your actual size of bra?
What size do you want to have?
What would you like to change?
Pictures of area that you want to improve
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