Ask estimate for Gastring Ring

Civility :

Name* :

Family name* :

E-mail* :

Leave blank :

Address* :

Postal code * :

Town* :

Country* :

Telephone* :

Hours when you can be joined (E) :

Occupation* :

Have a valid passport * ?

Yes No

Sex :

Female Masculine

Age :

Cut :

Weight :

Since how long do you think of having recourse to the cosmetic surgery ?

With which type of surgery do you wish to have recourse ?

Which are your possible dates of stay for this intervention ?

Did you already consult an aesthetic surgeon ?

Yes No

If so, why and when ?

Summers you smoker ?

Yes No

if yes how much by day and since how many years ?

Do you have allergies ?

Yes No

If so, with which (S) drug (S) or produced (S) ?

Do you have a cardiovascular disease ?

Yes No

If yes which ?

Did you already have phlebites - pulmonary Embolism ?

Yes No

So yes to indicate the treatment ?

Do you have the diabetes?

Yes No

Hepatitis

Yes No

Asthma

Yes No

Nephropathy

Yes No

Neurological

yes No

If yes which ?

Arterial hypertension

Yes No

cutaneous Disease

Yes No

if yes which ?

To indicate the treatment ?

Did you already have a depression ?

Yes No

Do you suffer from another known disease ?

Yes No

If so, which ?

Do you have family antecedents of breast cancer (for the patients asking a surgery of the centres) ?

Yes No

you under treatments medical ?
(aspirine, anticoagulants...)

Which

Do modes of contraception

Heal?

Normally Cheloïde

Suffer from :

HTA

Diabetes

Hyperlipémie

Apnea of the sleep

Sterility

Joint pains (knees, back)

Backward flow or of hernia hiatale, so yes to specify made explorations and the result (Fibroscopie, TOGD....)

Take drugs ?

However yes specify :

Did you consult a psychiatrist?

However yes specify :

Have undergoes a surgical operation ?

However yes specify :

Start date of obesity

Factor starting

During meal I am used again myself

I nibble between the meals

I accompany my meals by sodas or of sweetened drinks

I rise the evening to eat

I eat at specific times

When I have a pang of hunger

I often eat

I privilege food

On a scale from 1 to 10

I like to eat sweetened :

I like to eat salted :

Which ?

do you Have remarks or suggestions ?

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Nationality* :
to allow us to check if you need a visa for Tunisia

Starting airport :

Hotels

Formula wished :

So other, which ? :

Accompanying :

Yes No

If yes, specify child (age), adult :

Ask estimate for Gastring Ring

Marital status

Medical part

Surgery requested since

Medical antecedents

Food consumption survey

Surgical antecedents

Treatments

Your stay

Galerie photos