Personal Information


General information

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

Surgical procedures

Your request for an operation

Medical Information

What is your present weight ?
What is the maximum weight you reached ?
What is your size ?   cm
What size is your bra (for breast related surgical operations) ?
What bra size would you like to have?
Do you smoke ?
If yes, how many cigarettes per day?
If yes, since when ?
Did you stop smoking?
If yes, since when?
Do you drink alcohol ?
If yes, how frequently ?
Are you taking any medicine?
If yes, what are they?
Are you allergic to specific medical components?
If yes, which ones
Are you allergic to latex?
Other allergies
Do you suffer from hypertension ?
Are you diabetic ?
Do you have cholesterol?Yes No
did you ever have phlebitis ?
Did you ever have a nervous breakdown?
Do you have a viral or chronic disease?
If yes, what are they?
Other medical elements to mention
Do you user contraceptives? , If yes, which ones
How many pregnancies have you had?
In the last six months ?
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.