1. Your Contact Details Name* Address* Address 2 City/Town* State/Province* ZIP/Postal Code* Country* Email Address* Phone Number* Next 2. Family Doctor Contact Details Family Doctor Name* Company* Family Doctor Address* Address 2 City/Town* State/Province* Zip/Postal Code* Country* Phone Number* Back Next 1. Your Contact Details 3. What is your height in feet and inches? (Remove shoes before measuring.)* 4. What is your current weight in pounds?* 5. What is your gender?* Female Male 6. What surgical procedures would you like? Aesthetic surgery? Reconstruction? Hand/Wrist/Elbow? 7. Is this a medical vacation? Yes No 8. Has any family member suffered from any of the following ailments? (Please select all that apply.)* Bleeding Disorder Heart Disease High Cholesterol Hypertension Type 1 Diabetes Type 2 Diabetes None of my family members suffers from any of these ailments Prefer not to answer 9. Do you suffer from any of the following ailments? (Please select all that apply.) Adrenal Insufficiency Allergies Bleeding Disorder Deep-vein Thrombsis Diabetes Heart Disease Hepatitis B Hepatitis C HIV Hypertension Hyperthyroidism Hypothyroidism Keloid Have you ever had a cardiac arrest? Are you currently on medication? Do you drink alcohol? Do you smoke cigarettes? Are you pregnant? Do you plan to have children? Are you breast feeding? Do you plan to breast feed? I do not suffer from any of these ailments Prefer not to answer 10. If you have had a keloid please state where on your body and attach a picture of it. Enter Captcha Code to submit Back Submit Thank you for contacting us. Please turn on javascript to submit your data. Thank you! Created with BreezingForms Lite - Get BreezingForms Full Version!
