Cosmeticium Medical History Form

We will send your medical form copy to your case manager too

If you know body measurements

Do you have a contagious disease?

This questionnaire you filled in and the information you provided will affect the course of treatment, check the correctness and check the box below. The information you provide is under guarantee for data security and cannot be shared with anyone other than your doctor. Based on the information you provided, your operation will be planned and a price quote will be given to you, so you will know and accept that there would be changes in the plans if the information given above is mistake or not true. I read it and approve it