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Demande de devis chirurgie esthetique
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Personal Information
Civility: *
Select
Miss
Ms.
Mr.
Name :*
First name :*
Age: *
years
Nationality: *
Address:
Zip code:
City:
Country:
Email: *
Confirmation email: *
Password: *
More than 6 characters
Occupation
Landline:*
Mobile Phones: *
General information
When do you prefer to have your surgical operation?(day/month/year)
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For how long have you been determined to undergo the surgical operation of your choice?
Did you ever meet a cosmetic surgeon for the purpose?
Yes
No
If yes, what did he/she recommend?
Reason behind the request for the operation
The surgeon's preliminary diagnosis will be based on the information you provide in the medical questionnaires and your photos. These constitute your medical file, according to which you will be given a medical opinion and a quote. Please try to make your answers and comments as clear as possible in order to help us respond to your request with as mu_ch precision as possible.
Surgical Information
Did you ever have a surgical operation ?
Yes
No
If yes, which one(s) and when ?
Did you ever have a cosmetic surgery ?
Yes
No
If yes, which one(s) and when ?
Surgical procedures
Do you want to get a hair transplant?
Yes
No
Do you want to do any other operation?
Yes
No
Your request for an operation
First choice you made *
Choose
Liposuction
Abdominoplasty (Tummy tuck)
Bypass
Nose surgery or Rhinoplasty
Breast enlargement
Change of prosthesis
Breast reduction
Breast uplift
Fat injection in the breasts
brazillian butt lift
Fat injection in the face
Fat injection in the caives
fat grafting
arm lift
thigh lift
Gynecomastia
Pectoral implants
Lifting cervico-facial
Genioplasty
eyelids surgery
Increased volume of Lips
Reduces wrinkles
Teeth Whitening
buttocks implants
calf volume augmentation
vagina rejuvenation
hymenoplasty
vagina lips reduction
eye lasik
thalassotherapy
Crowns
Dental Implants
Second choice you made
Choose
Liposuction
Abdominoplasty (Tummy tuck)
Bypass
Nose surgery or Rhinoplasty
Breast enlargement
Change of prosthesis
Breast reduction
Breast uplift
Fat injection in the breasts
brazillian butt lift
Fat injection in the face
Fat injection in the caives
fat grafting
arm lift
thigh lift
Gynecomastia
Pectoral implants
Lifting cervico-facial
Genioplasty
eyelids surgery
Increased volume of Lips
Reduces wrinkles
Teeth Whitening
buttocks implants
calf volume augmentation
vagina rejuvenation
hymenoplasty
vagina lips reduction
eye lasik
thalassotherapy
Crowns
Dental Implants
Third choice you made
Choose
Liposuction
Abdominoplasty (Tummy tuck)
Bypass
Nose surgery or Rhinoplasty
Breast enlargement
Change of prosthesis
Breast reduction
Breast uplift
Fat injection in the breasts
brazillian butt lift
Fat injection in the face
Fat injection in the caives
fat grafting
arm lift
thigh lift
Gynecomastia
Pectoral implants
Lifting cervico-facial
Genioplasty
eyelids surgery
Increased volume of Lips
Reduces wrinkles
Teeth Whitening
buttocks implants
calf volume augmentation
vagina rejuvenation
hymenoplasty
vagina lips reduction
eye lasik
thalassotherapy
Crowns
Dental Implants
Other treatments
Medical Information
What is your present weight ?
Kg
What is the maximum weight you reached ?
Kg
What is your size ?
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cm
What size is your bra (for breast related surgical operations) ?
What bra size would you like to have?
Do you smoke ?
Yes
No
If yes, how many cigarettes per day?
If yes, since when ?
Did you stop smoking?
Yes
No
If yes, since when?
Do you drink alcohol ?
Yes
No
If yes, how frequently ?
Are you taking any medicine?
Yes
No
If yes, what are they?
Are you allergic to specific medical components?
Yes
No
If yes, which ones
Are you allergic to latex?
Yes
No
Other allergies
Do you suffer from hypertension ?
Yes
No
Are you diabetic ?
Yes
No
Do you have cholesterol?Yes
No
did you ever have phlebitis ?
Yes
No
Did you ever have a nervous breakdown?
Yes
No
Do you have a viral or chronic disease?
Yes
No
If yes, what are they?
Other medical elements to mention
Do you user contraceptives? , If yes, which ones
How many pregnancies have you had?
0
1
2
3
4
5
In the last six months ?
Yes
No
Your photos
Recevez votre devis en 48h dès réception de vos photos
Photo 1:
Photo 2:
Photo 3:
You may add more photos any time by connecting to your personal account on the website.
Cordially
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