Facial Plastic Surgery Body Contouring Medical Spa Services Reconstructive Plastic surgery Follow Up System     Subscribe/Unsubscribe   Bin Ham Building   Next to Bur Juman centre   P.O.Box : 25503   Dubai, U.A.E   Phone No: +971 4 3529292   Fax No: +971 4 3523366     www.surgerydubai.com                  Note: For this enquiry to reach us you must provide a valid email address.       PLEASE FILL THIS FORM TO SERVE YOU BETTER Name: Surname: Postal Address: Date of Birth: -DD- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ----MM----- January February March April May June July August September October November December ---YY--- 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Weight and Height: Weight:   Height: Country: Select Country ----------------------------------------- United Kingdom United States of America Australia New Zealand ----------------------------------------- Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barmuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burma (Myanmar) Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire (Ivory Coast) Croatia (Hrvatska) Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador England Equatorial Guinea Eritrea Estonia Ethiopia Eurasia Falkland Islands (Islas Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong S.A.R. 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Rep. of the Congo) Zambia Zimbabwe Others Telephone: Fax: Email Address: Occupation: Selected Surgical Procedure (For multiple selections please hold down the Control key and make your selections with your mouse.) None Breast Augmentation Breast Lift Surgery Breast Reduction Liposuction Abdominoplasty Rhinoplasty Blepharoplasty Brow Lift Cheek Augmentation Chin Augmentation Otoplasty Lip Augmentation Hair Transplant Why are you considering this procedure ? If you are currently consulting a Psychiatrist or Psychologist Have you discussed your intention of having the above mentioned surgery Yes   No Have you ever been treated for psychiatric illness? This includes depression. Yes   No Would it be possible to get a comprehensive report from your physician/psychiatrist in terms of your condition ? Yes   No Have you suffered from previous deep vein thrombosis, i.e. blood clots, developing in the leg following long air flights, long hospital stays, etc ? Yes   No Have you ever abused drugs or any substance ? Yes   No Current and prescribed Medication you are taking Past Medical History that needs mention Allergies What are your concerns, worries and fear about having this procedure Have you consulted a surgeon for this procedure ? If so, what was the plastic surgeon name and what was his plan of operation ? Do you drink or smoke ? Give Details Yes   No Cigarettes / Day Drinks / Day Have you or your family ever had difficulties with General Anaesthetic ? Yes   No Are you prone to KELIODS or poor scaring ? Yes   No Have you ever been ANAEMIC ? Yes   No If a blood transfusion should be necessary, would there be any reasons at all why you would refuse it ? Do you have ASTHMA ? Yes   No Do you have LUNG DISEASE ? Yes   No Do you have HIGH BLOOD PRESSURE ? Yes   No Do you have any known HEART problems ? Yes   No Have you ever been JAUNDICED ? Yes   No Are you on the "PILL" or any other HORMONE ? Yes   No Do you or any relatives have DIABETES ? Yes   No       Copyright © 2008, Surgery Dubai - Cosmetic & Reconstructive Surgery Testimonial | Disclaimer | Feedback | Sitemap | XML