Academic degree
Name
Surname
Street
City
Post Area Code
Phone No.
e-mail address
Where did you learn about us
Birth date
Sex
Chest circumference below breasts
Age
Height
Birth certificate No. / ID
Weight
Allergies:
Notes:
Description:
Preferred date:
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::
Invoicing address: Přípotoční 1528/2 10100 Praha 10 ID No.: 04173244 VAT No.: CZ04173244
Consulting centre: Myslíkova 6, 12000 Praha
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WhatsApp 00420602205822
00420728700688
info@topczechclinics.cz
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Euro – 2201410275/2010 IBAN – CZ9520100000002201410275