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Send a quote request form

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
 
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 than 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 ? :   Yes  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 ? :   Yes No
If yes, what medication & since when ? :  
For which reason/disease ? :  
Are you currently under any treatment ? :   Yes No
If yes, since when ? :  
For which reason/disease ? :  
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
f 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 ? :/td>  
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.
 
 

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