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General Information First Name: Email Address: Height (cm): Passport Number: Gender : Male Female Date of Birth : Day12345678910111213141516171819202122232425262728293031 Month123456789101112 Year190019011902190319041905190619071908190919101911191219131914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010 Preferred Language : Select LanguageArabicEnglishGermanMalayuBurmeseFilipinoJapaneseThaiCambodianFrenchKoreanVietnameseChineseDanishSwedishNorwegian Nationality: Country...AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua & BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaireBosnia & HerzegovinaBotswanaBrazilBritish Indian Ocean TerBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCayman IslandsCentral African RepublicChadChannel IslandsChileChinaChristmas IslandCocos IslandColombiaComorosCongoCook IslandsCosta RicaCote D'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerGabonGambiaGeorgiaGermanyGhanaGibraltarGreat BritainGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuyanaHaitiHawaiiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalaysiaMalawiMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMidway IslandsMoldovaMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNambiaNauruNepalNetherland AntillesNetherlands (Holland, Europe)NevisNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorwayOmanPakistanPalau IslandPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalPuerto RicoQatarRepublic of MontenegroRepublic of SerbiaReunionRomaniaRussiaRwandaSt BarthelemySt EustatiusSt HelenaSt Kitts-NevisSt LuciaSt MaartenSt Pierre & MiquelonSt Vincent & GrenadinesSaipanSamoaSamoa AmericanSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTahitiTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks & Caicos IsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuelaVietnamVirgin Islands (Brit)Virgin Islands (USA)Wake IslandWallis & Futana IsYemenZaireZambiaZimbabwe Last Name: Age : Weight (kg): Mobile: Address:
First Name: Email Address: Height (cm): Passport Number:
Gender : Male Female
Last Name: Age : Weight (kg): Mobile:
Address:
Contact Person in case of emergency Name: Email Address: Phone : Address:
Surgery details Surgery: Procedure 1Breast ImplantsBreast LiftBreast ReductionBreast CorrectionMale Chest ReductionLiposuctionTummy TuckNose SurgeryFaceliftForehead LiftNeck LiftEyelid SurgeryChin ImplantCheek ImplantThighs LiftArms LiftButtocks LiftButtocks ImplantsMale to FemaleFemale to MaleLasikHair TransplantBotoxSkin TreatmentVaricose Vein Other Surgery: What results do you expect? Questions to the Surgeon Surgery Date : Fly home on :
Surgery: Procedure 1Breast ImplantsBreast LiftBreast ReductionBreast CorrectionMale Chest ReductionLiposuctionTummy TuckNose SurgeryFaceliftForehead LiftNeck LiftEyelid SurgeryChin ImplantCheek ImplantThighs LiftArms LiftButtocks LiftButtocks ImplantsMale to FemaleFemale to MaleLasikHair TransplantBotoxSkin TreatmentVaricose Vein
Other Surgery:
What results do you expect?
Questions to the Surgeon
Surgery Date : Fly home on :
MEDICAL Conditions No Yes Diabetes problems Thyroid problems Heart problems Lung problems Blood Pressure problems Kidney or Liver problems No Yes Blood disorders Previous/current history of cancer HIV or AIDS Neurologic problems Anesthesia problems Nervous Breakdowns or Depression If you have answered YES to any of the above, please specify: If you have any medical condition not mentioned above, please specify:
FOR WOMEN ONLY No Yes Do you take birth control pills hormone replacement , or wear a hormone patch?? Are you pregnant now? Are you planning any more pregnancies? How old is your youngest child? (Month & Year) When did you last breastfeed? (Month & Year)
ADDITIONAL INFORMATION Have you been hospitalized or had surgery within the past 12 months? Yes No If yes, when? If yes, what was the reason for this? Do you have implants or any metal objects in body? Yes No If yes, please specify: Do you have difficulty with healing or scarring? Yes No Do you have any allergies to food, drugs, etc? Yes No If yes, please specify: List all medications you currently take including dosage for each:List all vitamins or food/nutritional supplements you currently take: Have you ever taken any MAO inhibitor such as Nardil, Marplan or Parnate? Yes No If yes, when was your last dose? Have you ever taken an anticoagulant like Coumadin, Heparin, or a daily Aspirin? Yes No If yes, when was your last dose? Do you smoke? Yes No If yes, how much do you smoke? If yes, when did you last smoke? Do you drink alcohol? Yes No If yes, how much do you drink?
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