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Tunisia Health Beauty agence de tourisme tunisiaHealthAndBeauty

Ask estimate for Aesthetic Surgery

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Marital status

Civility :
Name* :
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Address* :
Postal code * :
Town* :
Country* :
Telephone* :
Hours when you can be joined (E) :
Occupation* :
Have a valid passport * ?

Medical part

Sex :
Age :
Cut :

Surgery requested

Since how long do you think of having recourse to the cosmetic surgery ?
With which type of surgery do you wish to have recourse ?
Which are your possible dates of stay for this intervention ?
For the requests for increase mammaire :
Size of your bonnet of bra :
Cut wished :

Medical antecedents

Did you already consult an aesthetic surgeon ?
If so, why and when ?
Summers you smoker ?
If yes how much by day and since how many years ?
Do you have allergies ?
If so, with which (S) drug (S) or produced (S) ?
Do you have a cardiovascular disease ?
If yes which?
Did you already have phlebites - pulmonary Embolism ?
If yes to indicate the treatment?
Do you have the diabetes ?
Si yes which ?
Arterial hypertension
Cutaneous disease
if yes which ?

To indicate the treatment ?
Did you already have a depression ?
Do you suffer from another known disease ?
If so, which ?
Do you have family antecedents of breast cancer (for the patients asking a surgery of the centres) ?
Summers you under treatments medical ?
(aspirine, anticoagulants...)
Do modes of contraception
Heal ?

Surgical antecedents



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Your stay

Nationality* :
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