| CIVIL STATUS |
| Name*
: |
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| Surname*
: |
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| E-mail*
: |
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| E-mail
2 : |
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| Adresse*
: |
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| Mail Codel* : |
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| Ville*
: |
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| City*
: |
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| Telephonee* : |
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| Mobile* : |
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| Hours when you can be joined by an assistant of “mysurgery”: |
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| Occupation: |
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| Have a valid passport * ? |
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| How or by whom you knew scultura.com? |
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MEDICAL PART |
| Sex
: |
Female
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| Age :
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| height
: |
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| Weight
: |
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SURGERY REQUESTED: |
Since how long you have been thinking
to have recourse to plastic surgery? |
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To which type of surgery you wish
to have recourse? |
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| Which are your possible dates of stay for this intervention ? |
| From |
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| to |
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| For the requests of mammary increase: |
| Size of your bra: |
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| The size wished for : |
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MEDICAL ANTECEDENTS |
| Have you already consulted an aesthetic surgeon? |
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| If you have, why and when? |
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| Have you been operated before? |
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| If you have, which surgery and when? |
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| Do you have allergies? |
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| If you do, to which drug(s) or product(s)? |
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| Do you have a cardiovascular disease? |
Yes
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| Cardiopathy |
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| If you do what are they? |
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| Did you previously have phlebitis - pulmonary Embolism? |
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| If you did, please indicate the treatment? |
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| Do you have diabetes? |
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| If you do to indicate the treatment? |
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| Hepatitis |
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| Indicate the treatment? |
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| Asthma |
Yes
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| Indicate the treatment? |
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| Nephopathy |
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| which? |
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| Neurological |
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| which? |
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| Psychiotic |
Yes
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| which? |
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| Arterial hypertension |
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| Indicate the treatment? |
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| Arterial hypotension |
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| Indicate the treatment? |
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| Skin disease |
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| which? |
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| indicate the treatment? |
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| Did you previously have a depression? |
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| Do you suffer from another known disease? |
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| If you do, what is it? |
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| Do You have family antecedents of breast cancer (for patients asking for breasts surgery )? |
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| Do you smoke? |
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| If you do how many cigarettes by day and since how long? |
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SURGICAL ANTECEDENTS |
| Which? |
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| Do you Consume alcohol? |
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If you do how much by day and since
how long? |
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| Do you Consume tranquillizing products? |
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If you do, how much by day and since
how long? |
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| Do you consume aspirin? |
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How much by day and since
how long? |
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| anticoagulant? |
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How much by day and since
how long? |
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| Do you Bleed easily? |
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| Heal? |
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TREATEMENTS |
| What are the drugs which you currently take? (Mention if you take aspirin systematically or with a pill). |
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| What are the drugs which you took recently? |
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Do You have any other remark
or suggestions? |
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| Photographs: |
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- The photographs must be in JPEG format
- The size of each file should not exceed 3 Mo
- The duration of the remote loading depends on the size of your photographs and your mode of connection to Internet
- Attach your photograph while clicking on “To traverse”
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YOUR STAY |
Nationality* :
( to check if you need a visa to Tunisia ) |
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| Airport of departure: |
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| Desired dates: |
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| Category of hotel: |
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| If other, please indicate it? : |
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| companion : |
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| please specify child (age) or adult: |
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