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Medical Form                                                                                                                                                    Once we have assessed your requirements I will contact you with a surgery price, and any extras involved.

Online assessments
Please send clear digital photographs of the area(s) of your body where the surgical procedure(s) is / are required, these will be given to the Surgeon.

What photographs are required and why do you ask for them?  Many clients are under the impression that they need lets say - abdominal liposuction, when in fact they really need a Full Abdominoplasty. There is no way for us to know what procedure is right for you without these photographs and makes giving the right advice for you impossible.
So photographs are ESSENTIAL to enable us to make an initial online assessment.

Specific photos for Abdominoplasty

  • one leaning forwards a little without breathing in.
  • one bending forward without breathing in.
  • one sitting on the bed/chair taken from the front and side.
  • left and right profile

Excess Skin Picture: Loose skin folds can sometimes be demonstrated by holding the extra skin for a photograph. Some scars and can also be demonstrated with pictures.

Specific photos facial procedures

  • one smiling, taken as close as possible. 
  • one without smiling taken as close as possible.
  • left and right profile 

Specific photos for nose surgery

  • looking up the nose.
  • looking down the nose.
  • left and right profile

If you feel that other pictures better demonstrate your concerns, please include those views also.  

If you would like to send a digital photo then please This e-mail address is being protected from spam bots, you need JavaScript enabled to view it . Please include your name and email address in the body of the email.

 
Please fill in all fields marked with a *
General Information:
First Name: *
Last Name: *
Date of Birth:
Day:
Month:
Year:
Telephone Number: *
Fax:
Mobile:
Email Address: *
Verify Email Address: *
Passport Number:
Gender:
Postal Code:
Country:
Occupation:
Next of kin details, to be contacted in case of emergency only;
First Name NOK:
Last Name NOK:
Relationship NOK:
Contact number NOK:
How did you hear about Cosmedicare4u?
Please answer the following questions fully.The information is treated as strictly confidential and is necessary to insure that the key health aspects are considered prior to your consultation in Cyprus. Plastic Surgery is a serious Surgical Procedure.
How would you say your skin heals?
If you smoke how many a day?
Do you have a smokers cough? Yes
No
How is your general health?
What is your blood group?
Does your religion prohibit you from having a blood transfusion in the unlikley event that you may need one? Yes
No
Are you being treated or have you been treated for any of the following?
If yes or no, past or present, please select appropriate boxes, give full details and list medications prescribed in the details section further down the form.
Anaemia
Asthma
Contraceptive pill
HRT Hormone Replacement
Blood pressure
Breathing problems eg Bronchitis Chronic cough
Deep Vein Thrombosis Blood Clots
Depression
Diabetes
Drug dependance
Epilepsy
Eye problems eg dry eyes glaucoma
Heart problems
Jaundice
Stroke
Phlebitis
Any other conditions not mentioned above and further details including medications for the ones you did list:
Do you have any allergies associated with foods medication surgical tape elastoplast:
Have you had ANY surgical procedures before that required you to have a general anesthetic? If yes, please supply full details:
Have you ever had any negative reactions to local or general anesthetics? If yes, please supply full details:
Any keloids or bad scarring Yes
No
Ever had a blood transfusion? If yes please give full details
Breast Surgery:
When was your last mammogram and what was the result?
Has any family member suffered from breast cancer? If yes, please supply details:
Have you had any breast lumps cysts? If yes please supply details:
If it were found to be necessary would it be possible to discuss your medical history with your GP As cosmetic surgery is an elective procedure we would only contact him her directly with your express permission: Yes
No
If yes please supply GP details:
Full Name:
Telephone:
Choice of non-surgical Procedure(s):
Abdominoplasty tummy tuck
Breast augmentation
Breast lift
Breast reduction
Ear surgery Otoplasty
Eyelid surgery
ForheadBrow lift
Face Lift surgery
Laser skin resurfacing
Liposuction Lipoplasty
Lip augmentation
Rhinoplasty Nose surgery
Choice of non-surgical Procedure(s):
Botox
Fat Fascia transfer
Restylane
Artecol
You may also choose to have both surgical and non-surgical procedures at the same time.
Height:
Metres:
Feet:
Weight:
LB's:
KG's:
Preferred Accommodation Details:
Preferred Diet:
Arrival Year:
Month:
Day:
Have you read our terms and conditions? (Pop up Window) Yes
No
Additional Comments?

 
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