Health Pre-Assessment Form

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 *

Health Information

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. *

Questions for Female Patients

Are you considering pregnancy? *

NoYes

Have you given birth? *

NoYes

How many times have you given birth? *

Are you currently breastfeeding? *

NoYes

Application Information

You can select more than one option.

Reason for Application *

Breast Reduction Breast Enlargement Breast Lift Breast Reconstruction Mini Facelift Lip Reduction Skin Cancer Surgery Lip Lift Tummy Tuck

Other Procedures

Pressure Sore Treatment Rhinoplasty Facelift / Facial Rejuvenation Eyelid Aesthetics Neck Aesthetics Eyebrow and Forehead Aesthetics Temporal Lift Ear Aesthetics / Otoplasty Liposuction Lipedema Treatment Arm Lift Thigh Lift Leg Aesthetics Hip / Buttock Shaping Genital Aesthetics Almond Eye Aesthetics Lip Aesthetics Botulinum Toxin Applications Filler Applications PRP / Thread Lift Applications Mesotherapy / Skin Booster Hair Mesotherapy Hand Surgery Head and Neck Reconstruction Burn / Wound Treatment Microsurgery / Tissue Transfer Cancer Surgery Secondary / Revision Breast Reduction

Other reason

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 *

Confirmation

Fields marked * are required.

View Information NoticeI have read the information notice and have been informed.

I give explicit consent for processing my personal and health data for pre-evaluation.

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