Patient Registration

Date Of Birth*

Name*

First Name Last Name

Email*

Phone*

What date are you considering surgery?*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Gender*

Height*

Weight*

Date of Birth*

Requested procedure/s*

Breast
Body
Face
Dental
SRS

Specific procedures requested?

Do you have any medical conditions?*

Yes
No

If yes please describe what they are*

Are you on any medications?*

Yes
No

If yes list them and dosage/s taken daily*

Heart disease*

Yes
No

Diabetes*

Yes
No

Deep vein thrombosis*

Yes
No

Hypertension*

Yes
No

Asthma*

Yes
No

Bleeding tendenies*

Yes
No

Hyperthyroidism*

Yes
No

Hepatitis*

Yes
No

HIV*

Yes
No

Keloid scarring*

Yes
No

Cancer*

Yes
No

Major Operation*

Yes
No

If yes what was the procedure and how long ago?*

Any underlying disease and what is it?*

Drug Allergies*

Yes
No

If yes which drugs?*

Vitamins and supplements*

Yes
No

Depression*

Yes
No

Smoke Cigarettes*

Yes
No

If yes how many per day?*

Alcohol Consumption*

Don't Drink
Socially
Moderate
Heavy

(All breast procedures including reduction) Size you are now and size you would like to be (any other requirements or special requests)?*

Breast implants

Any other requirements or information you would like to add

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Consent

I agree to Medication Tours' terms and conditions.

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