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Medical Travel Europe
Für ein gesundes und glückliches Leben.
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Weight loss
Gastric Sleeve
Gastric balloon
Gastric Bypass
Gastric Botox
Aesthetic surgery
Breast lift
Breast augmentation
Breast reduction
Brazilian Butt Lift
Hair transplant
Hair transplant with Dr. Bircan
Hair transplant at Turkey Hair Academy
Dental surgery
Eye laser
Contact
Medical history form
Home
Weight loss
Gastric Sleeve
Gastric balloon
Gastric Bypass
Gastric Botox
Aesthetic surgery
Breast lift
Breast augmentation
Breast reduction
Brazilian Butt Lift
Hair transplant
Hair transplant with Dr. Bircan
Hair transplant at Turkey Hair Academy
Dental surgery
Eye laser
Contact
Medical history form
Medical history form
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Medical history form
Please fill out this form so that we can give you an individual assessment.
Please enable JavaScript in your browser to complete this form.
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
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
Click or drag a file to this area to upload.
Upload Videos
Click or drag a file to this area 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?
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