Agency for plastic surgery, dermatology and stomatology
consultation free of charge
the best clinics
individual care

ENTRY QUESTIONNAIRE

Contact data

Academic degree

Name

Surname

Street

City

Post Area Code

Phone No.

e-mail address

Where did you learn about us

Personal data

Birth date

Sex

Chest circumference below breasts

Age

Height

Birth certificate No. / ID

Weight

Other

Allergies:

Notes:

Required surgery/intervention

Description:

Preferred date:

Do you wish us to order your transport services
Do you wish to order your accommodation services

Client´s health record

Check out illnesses you have gone through in the column Past

Check out any persistent symptoms in the column Present

Illnesses

Past

Present

Comments

Blood

Cancer

Liver

Blood pressure

Pacemaker

Cardiac

Metallic implants

Pressure skin diseases

Gastro-intestinal diseases

Immunity disorders

Backbone disorders

Diabetes

Epilepsy

Pregnancy

Surgeries

HIV/AIDS

Do you take any calcium canal blockers?:

Do you take any aminoglycoside antibiotics? (Gentamycin, Tobramycin, Streptomycin, Amicacin)::

Do you use any retinoids or quinolons?: (Tretinoin, Transretin acid, Retinol, Retinyl-Palmitate, Retinyl-Acetate)

Formery used fillers:

Former keloid/hypertrophic scars:

Former surgeries (medical treatment, aesthetic):

Face asymmetry:

Do you suffer from herpes:

Former radiotherapies:

Cigarettes or other narcotic substances (any replacement nicotine treatment, nicotine patches have to discontinued/removed two weeks before the surgery):

Do take any contraception?:

Have consulted your health condition at another clinic?:

Photo::






Consent to terms (Read contractual terms)


Invoicing address:
Přípotoční 1528/2
10100 Praha 10

ID No.: 04173244
VAT No.: CZ04173244

Mobil + WhatsApp
602205822
732451616

WhatsApp
00420602205822

00420728700688      


info@topczechclinics.cz

Account No.
CZK - 2301410272/2010
(Fio banka)