Free Estimate

Download the file, join your photographs and send it by postal mail.

As it is directed by the good practices charter, Chirurgiepro.net does not submit any file to other persons but an expert surgeon.

In order to allow our team of surgeons to evaluate your needs as well as possible, we invite you to fill this file with much accuracy.

This file does not engage you by any way. The pieces of information which appear in it (questionnaire + photographs) remain entirely confidential.

* The Heading that should be filled

MARITAL STATUS
Civility :	Mr Mrs. Miss
Family name * :
First name * :
E-mail * :
E-mail 2 :
Address * :
Zip Code * :
City * :
Country * :
Home phone * :
Mobile phone * :
Times when you can be joined by the assistant of chirurgiepro :
Profession* :
Do you have a valid passport * ?	Yes No
How or through whom have you known chirurgiepro.net ?
MEDICAL PART
Sex :	Female Masculine
Age :
Height :
Weight :
DESIRED SURGERY :
How long have you been looking for resorting to a plastic surgery ?
Which type of surgery do you want to resort to ?
Which are the possible dates on which you’ll be able to stay for an intervention ?
In case you ask for breast augmentation, you should provide us with,
The size of your bonnet of bra :
Desired size :
MEDICAL ANTECEDENTS
Have you already consulted an aesthetic surgeon ?	Yes No
If yes, why and when have you done it ?
Have you already been operated on ?	Yes No
If yes, which surgery and when ?
Do you have allergies ?	Yes No
If yes, to which drug (s) or product (s) ?
Do you have a cardiovascular disease ?	Yes No
Have you already had phlebitis ?	Yes No
Are you a diabetic ?	Yes No
Have you ever suffered from depression ?	Yes No
Do you suffer from another known disease ?	Yes No
If yes, what is it ?
Do you have family antecedents of breast cancer (for the patients asking for a breast surgery) ?	Yes No
Are you a smoker ?	Yes No
If you are, why and for how long ?
TREATEMENTS
Which are the drugs you are currently taking ? (If you regularly take aspirin or the pill, also mention it).
Which are the drugs you have taken recently ?
Do you have any remarks or suggestions?
Photos :
The photographs must be in format JPEG The size of each file should not exceed 3 Mo The duration of the downloading depends on the size of your photographs and your Internet connection. Join your photograph by clicking on “TO BROWSE”
YOUR STAY
Nationality * : Let us check if you need a visa for Tunisia
Airport of departure :
Desired dates :
Hotel category :	Sunny club (3*) Sol phébus (4*) El mouradi (5*) Autre
If other, which one ?
Accompanist :	Yes No
If so, specify child (age), adult :