Cosmetic surgery in Tunisia : Cosmetic surgery estimate



Blepharoplasty	Rhynoplasty

Liposuction	Otoplasty

Facelift	Hair transplants

Abdominoplasty	Breast surgery

Breast enlargement	Botox (Allergan Inc)

Gynecomasty	Esthetical Treatment

Other Procedures

Gastric Banding	Gynecology


Gastro-surgery	Orthopedy

Cosmetic surgery in Tunisia with Cosmetica Travel

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Forms

Cosmetic surgery estimate with photos

We would like to thank you for having visited Cosmetica Travel website. In order to allow us to answer your queries clearly and thoroughly and in the least possible time, we would like to advise you to fill in all the boxes of the present form and send us two photographs (front and side profile) of the parts of the body that need to be treated. These photographs are absolutely necessary to allow the surgeon to do the preliminary medical diagnosis as accurate as possible.
To preserve your anonymity, and in case of face surgery, you can cover your eyes. These photographs ought to reach us by mail or preferably by email.
NB: Only genuine application forms with photograph attached are to be considered by our surgeon.
All information submitted remains strictly confidential

Please use Internet Explorer to send the forms.

Surname* :

Forename* :

Date of birth* :

Profession :

Adress :

City :

Post code/ Zip code :

Country :

Nationality :

Nearest airoport :

Home phone :

Work phone :

Mobile phone :

If you accept to be contacted

by one of our team members

preferred contact time :


	Monday to Friday at 8h30 to 16h30

Fax :

E-mail* :

Procedure

Option1 :

Option2 :

Option3 :

Other :

How do you intend to send us your photos :

Hotel :

Arrangement:

Type of room :

Number of adults:

Number of children (6 to 12):

Number of children (less 6):

When will you consider travelling to Tunisia?

Excursion/Leisure
(not included in the package) :

Comments :

Personal information

Your size

Your current weight

What is the maximum weight you have reached?

What is your dress size ?

Chest

Waist

Do you smoke ?

Oui No

If yes, how many cigarettes a day ?

When did you start smoking ?

Have you stopped smoking ?

Yes No

Since when ?

Do you drink alcohol ?

Yes No

How often ?

Medical history

Are you currently taking any medications?

Are you currently under any treatment?

Yes No

If yes, since when?

Do you have any allergies?

Yes No

If yes, what are they?

Are you allergic to any medicines?

Yes No

If yes, which one ?

Others ?

Do you have diabetes ?

Yes No

Do you suffer from cholesterol ?

Yes No

Do you suffer from high blood pressure ?

Yes No

Do you suffer from anaemia ?

Yes No

Do you suffer from a blood condition ?

Yes No

Have you gone through depression ?

Yes No

If yes, what sort of depression ?

Surgical record

Have you had surgical procedures before ?

Yes No

If yes, which ones ?

Have you had cosmetic surgery ?

Yes No

If yes, on which part of your body ?

Gynecological and obstetrical record

Number of pregnancies ?

Number of children ?

Number of caesareans ?

Do you intend becoming pregnant ?

Yes No

If yes, when ?

In case of breast surgery

What is your cup size ?

Have you had mammography ?

Yes No

If yes, when ?

What was the outcome ?

Have you had breast cancer before ?

Yes No

Have you had history of breast cancer in the family ?

Yes No

If yes, which member of the family ?

Motivations

Since when have you wished for cosmetic surgery?

Why do you want to go through surgery?

Have you already consulted a plastic surgeon?

Yes No

If yes , for which type of operation?

Fields marked with an asterisk * are required.