| MARITAL STATUS |
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Civility : |
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| Family name * : |
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| First name * : |
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| E-mail * : |
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| E-mail 2 : |
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| Address * : |
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| Zip Code * : |
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| City * : |
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| Country * : |
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| Home phone * : |
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| Mobile phone * : |
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| Times when you can be joined by the assistant of chirurgiepro : |
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| Profession* : |
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| Do you have a valid passport * ? |
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| How or through whom have you known chirurgiepro.net ? |
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MEDICAL PART |
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| Sex : |
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| Age : |
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| Height : |
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| Weight : |
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DESIRED SURGERY : |
| How long have you been looking for resorting to a plastic surgery ? |
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| Which type of surgery do you want to resort to ? |
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| Which are the possible dates on which you’ll be able to stay for an intervention ? |
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| In case you ask for breast augmentation, you should provide us with, |
| The size of your bonnet of bra : |
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| Desired size : |
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MEDICAL ANTECEDENTS |
| Have you already consulted an aesthetic surgeon ? |
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| If yes, why and when have you done it ? |
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| Have you already been operated on ? |
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| If yes, which surgery and when ? |
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| Do you have allergies ? |
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| If yes, to which drug (s) or product (s) ? |
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| Do you have a cardiovascular disease ? |
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| Have you already had phlebitis ? |
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| Are you a diabetic ? |
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| Have you ever suffered from depression ? |
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| Do you suffer from another known disease ? |
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| If yes, what is it ? |
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| Do you have family antecedents of breast cancer (for the patients asking for a breast surgery) ? |
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| Are you a smoker ? |
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| If you are, why and for how long ? |
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TREATEMENTS |
| Which are the drugs you are currently taking ? (If you regularly take aspirin or the pill, also mention it). |
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| Which are the drugs you have taken recently ? |
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| Do you have any remarks or suggestions? |
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| Photos : |
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- 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”
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YOUR STAY |
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Nationality * :
Let us check if you need a visa for Tunisia |
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| Airport of departure : |
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| Desired dates : |
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| Hotel category : |
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| If other, which one ? |
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| Accompanist : |
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| If so, specify child (age), adult : |
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