+905374499936 adahealth@gmail.com
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+905374499936
adahealth@gmail.com
Medical Form
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Name *
Email *
Phone
Your preferred method of communication
Country and City ?
Procedure ?
Combine Procedure
Detailed Surgeries
Which month do you prefer for your operation? (if you are considering a date, please type below)
Date of Birth
Height
Weight
Please list any surgeries other than cosmetic surgeries you have undergone
Please list any cosmetic surgeries you have had
Please list any medical conditions you have – Sleep apnea,heart disease, hypertension, kidney disease, cancer, diabetes, hepatitis, seizures, depression, thyroid etc
Do you use any medication ?
Please list any allergies to medications you have
If you are female, how many pregnancies to term have you had?
Do you smoke ? if yes how many cigarettes /day ?
How often you drink alcohol ?
Have you had any problems with anesthesia in the past?
Will you come with a companion or alone ?
Where did you hear about us ?
If you have a Referral Code, Please type bellow