Surgero USA - Medical Questionnaire

Patient Pre-Consultation Form

Welcome to your next-step!
Please read carefully and answer the most accurate as by submitting this form you accept that the all information you provide here is accurate and correct.

In order to speed up your booking process and provide you a personalized treatment plan, our medical team will need photos & videos to evaluate your case.

For this matter we have prepared a Photo Instructions Guide;

Click Here to see Photo Instructions Document
Your Name*

First NameLast Name
E-Mail*
example@example.com
Phone Number*

Country CodeArea CodePhone Number
Country
Social MediaSearch EnginesReview WebsitesYouTubeAmbassadorsReferral
Medical Background

Please read carefully and answer most accurate.
Age*
Height *
in CM or Ft
Weight *
in KG or LBS
Have you had any surgeries before? (Including Births) *
If yes, please list them with their approximate dates (Month / Year)
Are you currently taking any medications? *
Please list any medications you are currently taking.
Is there anything you are allergic to? (Medications, dust etc.)*
If yes, please list them here.
Do you consume Alcohol / Tobacco Products / Drugs?*
If yes, please list them here and specify how often.
What kind of procedure are you interested in?*
What is your main goal?*
Please specift your desire to be considered by our medical team. If you have any wishpics, please also submit.
Desired Date for your Visit to Istanbul*

MonthDayYear
When do you plan to visit Istanbul for the procedure?
Photos & Videos *

Select Files
Please click button above and upload photos & videos from related areas to be evaluated from our medical team. Cancelof
Liability Waiver

By signing the box below you accept that the all information you provide here is accurate and correct.
Your Signature*

Clear
I understand that the all information I am providing here with Surgero is accurate and correct.
Date Signed*

MonthDayYear
It automatically chooses today's date for you!
Should be Empty:

Patient Pre-Consultation Form

Medical Background

Liability Waiver