Health Pre-Assessment Form

01

Basic Information

Fields marked * are required.

Name and Surname * Date of Birth * Country of Residence * Country * City Occupation * Weight * Height *

Mobile Phone *

Country Code Mobile Phone

For Turkey, leave the country code as +90 and enter 5431234567 or 05431234567. Spaces are not required.

E-mail *

02

Fields marked * are required.

Do you smoke? * Please specify * Do you drink alcohol? * Please specify *

Do you use any medication regularly? *

No Yes

Please write the medication(s). *

Have you had any illness or surgery? *

No Yes

Please provide details. *

Do you have a chronic disease? *

No Yes

Please provide details. *

Do you have any allergies? *

No Yes

Please provide details. *

Do you use blood thinners or have a clotting problem? *

No Yes

Please provide details. *

03

You can select more than one option.

Have you had a previous procedure related to your application? *

NoYes

Please provide details. *

Approximate Budget When are you considering the procedure? * How did you hear about us? * Please specify *

04

Fields marked * are required.

Your answers are not public and are sent directly to the clinic management panel.