Breast - form - Coramed Beauty Surgery

Breasts surgery

In connection with planning to perform surgery in our clinic, please read the information about the procedure and consents to the procedure in the procedure description on our website.

First Name

Surname

Age

Height

Weight

Phone number

Do you have any chronic illnesses?

Do you take medication?

Did You have any previous procedures - general, plastic, beriatric surgery?

Do You suffer for allergies?

Did you have any anaesthesia problems in past?

Do You smoke?

Yes No

Breasts surgeries

Breast augmentation Breast lift Other

When was your last pregnancy?

How many times were You 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.

Breasts surgery

Urvi Chhatrala +44 7930 725520 +48519077911 (WhatsApp)

Urvi Chhatrala +44 7930 725520
+48519077911 (WhatsApp)