Please fill in this table and you can attach your photos to this email. Your personal information will be treated in the strictness of confidence.

For the medical condition please fill Yes or No.
 
General Information
 
Person to Contact in Case of Emergencies
 
Trip & Procedure Details
Planned Arrival Date Planned Departure Date
Which type of surgery are you interested in?
What results do you expect? Questions to surgeon
 

Medical Conditions

(please specify yes or no and please specify if you answer yes to any of the below)
Diabetes or blood sugar problems Yes No  Kidney or Liver problems Yes No 
Heart problems Yes No  Lung problems Yes No 
Blood pressure problems Yes No  Kidney or Liver problems Yes No 
Blood disorders Yes No  Previous/current history of cancer Yes No 
HIV or AIDS Yes No  Nervous Breakdowns/Depression Yes No 
Neurologic problems Yes No  Anesthesia problems Yes No 
Have you had or do you have any medical conditions not mentioned above?  
  Yes No 
 
Only for Women
Any birth control pills, hormone replacement medication or wear a hormone patches? Yes No 
Are you pregnant now? Yes No  Are you planning any more pregnancies? Yes No 
When did you last deliver a baby? When did you last breastfeed?
 
Medical History
Have you been undergone any kinds of surgery or received medical care within the past 12 months?
If yes, when and what was the reason for this?
Do you have implants or any metal objects in your body?
If yes, when and what was the reason for this?
Do you have difficulty with healing or scarring?
If yes, please specify
Do you have any allergies to food, drugs, etc?
If yes, please specify
List of the medications you are currently taking now ( including dosage for each)
List of all kinds of vitamins or food/nutritional supplements you are currently taking
Have you ever taken a MAO inhibitor such as Nardil, Marplan or Parnate?
If yes, when was your last dose?
Have you ever taken an anticoagulant such as Coumadin, Heparin, or a daily Aspirin?
If yes, when was your last dose?
Do you smoke?
If yes, how much do you smoke per day?
Do you drink alcohol?
If yes, how much do you drink per day?
 
Upload Pictures for Medical Evaluation by the Surgeon

It's very important for a plastic surgeon to visually evaluate the operated area and therefor we ask you to submit photographs to assist the doctors. Please be assured that all your info, including photos, is kept in strict confidence.

Upload 3 to 6 photographs, using the following guidelines:

  • Use a solid background and a tripod, if possible.
  • Take at least one frontal photo with the body centered and facing forward.
  • Take at least two profile (side view) photos, one from the left side and one from the right.
  • For breast or body surgeries: take photos from below your chin and down to your knees, with hands firmly at your sides.
  • For any type of facial surgeries: take photos from top of your head down to the neck.

Maximum 5 MB per file.