Plastic Surgery Application Form
Full Name
*
First Name
Last Name
What is your Gender
*
Male
Female
Other
Date of Birth
*
Email
*
Phone Number (with country code)
*
Please tell us about your family health history. If your family member was diagnosed with any of below mentioned diseases tell us who from your family and what type:
What is Your Weight?
*
What is Your Height?
*
What is Your BMI?
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Do you use or do you have history of using illegal drugs?
*
Please Select
Yes
No
Do you smoke? If yes, please tell us how often and how much:
*
Do you have any other addictions?
*
Check the conditions that apply to you:
*
Cancer
Cardiac disease
Diabetes
High blood pressure
None
Do you exercise regularly?
*
Yes
No
Do you have any allergies?
*
Have you beendiagnosed with fatty liver, cirrhosis, hepatitis or any other liver disease?
*
Yes
No
Have you been diagnosed HIV positive?
*
Yes
No
Please list any previous surgeries you have had:
*
Please list any current medications you are taking:
*
Please list any major illnesses you have had:
*
Please list any additional information you believe would assist in your health planning
Preferred type of surgery and date
*
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Patient declaration
I declare that I have truthfully completed this formand have not made any purposeful omissions.
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