PRE- CONSULTATION FORM

Thank you for visiting TUNISSURGERY website .

To be able to respond to your application in a clear, precise, and detailed manner, please fill out all the fields in every stages of the following form.

In addition to this form, you will have to send us the required pictures.

R equired p hotographs :

For body surgery
Body photographs of Front, Back and Profile.
For Face surgery
Face photographs of Front and Profile – both sides.

These pictures are essential for our surgical team to be able to establish a clear and accurate preliminary medical diagnosis.

We will be pleased to respond to you as quickly as possible.

Important : Only those including the required photographs and the Motivation Letter will be examined by our team.
A ll the information you supply to us will be treated with the strictest confidentiality.

 

 

Phone: 00 216 24 119 646

Skype :

E-mail : info@tunissurgery.com

Or If you would like to get started, please fill in the online consultation form below :
Your personal Details:
Name *:
Surname *:
Gender (M, F) *
Date of birth *:
Weight *:
Height *:
Address *:
Tel *:
Post code *:
Email address *:
Date ( d / m / y ) *: To
secret question *:
secret answer *:
Which surgery or treatment is required:
Orthopaedic Surgery *:
Cosmetic Surgery * :
For cosmetic surgery please attach photographs ( front and the two sides : right and left) of the area of your body to be treated.


General surgery *:
Please type in the name of the required procedure
General Medical history :
Do you smoke *
If yes, how many cigarettes per day
Do you drink alcohol *
If yes, how many units per day?
Do you suffer from any allergy to medication, food or any other products *
If yes , please list them.
Do you suffer from diabetes . *
Do you suffer or ever suffered from asthma, pneumonia or bronchitis? *
If yes, specify.
Do you have any heart condition ? *
If yes specify
Do you suffer from high blood pressure ? *
If yes what medication are you taking ?
Do your suffer from kidney disease *
If yes specify :
Do you suffer from liver or spleen disease *
If yes specify
Do you suffer from any disease not mentioned here ( Y,N) *
If yes specify
Have you had any surgery in the past *
If yes, specify kind of surgery and when?
Have you had any reaction to anaesthetic in the past *
If yes, specify the kind of reaction
Are you taking any medication *
If yes, list your medication here.
Questions you would like to ask your surgeon
Comments :

Fields compulsory *

   
 
DEVLOPED BY WEB DESIGNER COPYRIGHT FLAYIN PATIENT TUNISIA © 2008