Medical Travel Europe

Für ein gesundes und glückliches Leben.

Home
Weight loss
Aesthetic surgery
Hair transplant
- Hair transplant with Dr. Bircan
- Hair transplant at Turkey Hair Academy
Dental surgery
Eye laser
Contact
- Medical history form

Home
Weight loss
Aesthetic surgery
Hair transplant
- Hair transplant with Dr. Bircan
- Hair transplant at Turkey Hair Academy
Dental surgery
Eye laser
Contact
- Medical history form

Medical history form

You are here:

Home
Medical history form

Please fill out this form so that we can give you an individual assessment.

Personal details

Name *

First

Last

E-Mail *

Phone Number *

Adres *

Country / City *

Sex *

male
female

Date of birth *

DD. MM. JJJJ

Weight *

Height *

How did you find us?

Google
Instagram
Facebook
Ebay
Friend

Medical history

Medical conditions (kopieren)

Diabetes or blood sugar problems
Thyroid problems
Heart problems / conditions
Lung problems / conditions
Blood pressure problems
Kidney problems
Liver problems
Blood disorders
Previous / current history of cancer
HIV or AIDS
Nervous breakdowns or depression
Anesthesia problems
Umbilical hernia
Anemia
Allergies
Eating disorder
Chronic (infectie) diesease
Neurologic problems

If one or more have been clicked please explain

Have you been hospitalized, had surgery or received medical care before?

Yes
No

Do you have implants or any metal objects in your body?

Yes
No

Do you have difficulty with healing or scarring?

Yes
No

Do you have any allergies to food, drugs, etc.?

Yes
No

List all medication you currently take including dosage for each

List of all vitamins or food / nutritional supplements you currently take:

Have you ever taken a MAO inhibitor (antidepressants) such as Nardil, Marplan or Parnate?

Yes
No

Have you ever taken an anticoagulant such as Coumadin, Heparin or a daily aspirin?

Yes
No

Do you drink alcohol?

Yes
No

Do you smoke?

Yes
No

Treatments

Bariatric surgery

Which treatment do you want?

Gastric sleeve
Gastric bypass
Gastric balloon
Gastric botox

Plastic / aesthetic surgery

Body

Breastaugmentation
Liposuction
Breastlift
Brazilian Butt Lift (BBL)
Butt implants
Arm lift
Tummy Tuck
Thigh lift

Breast

Breast augmentation
Breastlift
Breast reduction
Gynecomasty

Face

Rhinoplasty
Facelift
Blepharoplasty (Eyelids)
Gynecomasty

Hair transplant

Eye laser

PRK / LASEK
iLASIK
ReLEx Smile

Teeth treatment

Eye laser (kopieren)

All-on-4
All-on-6
Full mouth
Hollywood Smile
Teeth whitening

Photos / Videos

Upload photos

Drag & Drop Files, Choose Files to Upload

Upload Videos

Drag & Drop Files, Choose Files to Upload

Important for: Liposuction, Tummy Tuck, BBL Squeeze your stomach and turn around

Other issus

Are there other things we need to know about, which we did not answer?

Data security agreement *

I agree to share this form with Medical Travel Europe

Website

We are a mediation agency for medical tourism and organize for our patients the stay and treatment in the areas of obesity, plastic and dental surgery, as well as hair transplants and eye lasers in Turkey.

Contact

Medical Travel Europe
Gas Street. 18
D-42657 Solingen / Germany

+49 (0) 212 88 132 884
+49 (0) 170 51 66 532
info@medicaltraveleurope.de

Treatments

Weight loss
Aesthetic surgery
Hair transplant
Dental surgery
Eye laser

Company

About us
Cooperation partners
Imprint
General conditions
Data protection

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