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

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

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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