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Plastic and Surgery in Tunisia

Free consultation

	We hope that you have found this website educational and informative. We would like to offer you a complimentary consultation. A preliminary consultation is offered to you, at no cost, with one of our experienced Surgeons, so that we can discuss your specific situation in detail. In order to allow us to answer your queries clearly and thoroughly and in the least possible time, we would like to advise you to fill in all the boxes of the present form and send us pictures ( front , back and side profiles) of the parts of the body that need to be treated. These pictures are absolutely necessary to allow the surgeon to do the preliminary medical diagnosis as accurate as possible.
	Personal Information
Civility (*)	MissMrsMr Donnée Invalide
First Name (*)	Donnée Invalide
Surname/family name : (*)	Donnée Invalide
Date of birth (*)	Donnée Invalide
Adress (*)	Donnée Invalide
City (*)	Donnée Invalide
Country (*)	Donnée Invalide
Phone number (*)	Donnée Invalide
Mobile phone (*)	Donnée Invalide
E-mail (*)	Donnée Invalide
Photo 1	Donnée Invalide
Photo 2	Donnée Invalide
Photo 3	Donnée Invalide
	In order to allow us to answer your queries clearly and thoroughly and in the least possible time, we would like to advise you to fill in all the boxes of the present form and send us pictures ( front , back and side profiles) of the parts of the body that need to be treated. These pictures are absolutely necessary to allow the surgeon to do the preliminary medical diagnosis as accurate as possible.
	May I contact you by phone?
Your choice	YesNo Donnée Invalide
At what time?	Donnée Invalide
Are you travelling alone?	Yes No Donnée Invalide
When do you intend to travel?	Donnée Invalide
Date go and return	Donnée Invalide
First Procedure	Donnée Invalide
Second Procedure	Donnée Invalide
Other treatments	Donnée Invalide
Since when did you want cosmetic surgery?	Donnée Invalide
Have you already consulted a plastic surgeon?	YesNo Donnée Invalide
If yes , for which type of operation?	Donnée Invalide
	General Information
Your current weight	Donnée Invalide
What is the maximum weight you had?	Donnée Invalide
Your size (cm)	Donnée Invalide
What is your dress size? Chest?	Donnée Invalide
What is your dress size? Waist?	Donnée Invalide
	Personal Information
Do you smoke?	YesNo Donnée Invalide
If yes, how many cigarettes a day?	Donnée Invalide
When did you start smoking?	Donnée Invalide
Have you stopped smoking?	YesNo Donnée Invalide
Since when?	Donnée Invalide
Do you drink alcohol?	YesNo Donnée Invalide
How often	Donnée Invalide
Are you currently taking any medications?	YesNo Donnée Invalide
If yes, what kind?	Donnée Invalide
	Gynaecological and obstetrical record (ladies)
Number of pregnancies if any?	Donnée Invalide
Number of children if any?	Donnée Invalide
Number of caesareans if any?	Donnée Invalide
Do you intend to be pregnant?	YesNoMay be Donnée Invalide
If yes, in how long?	Donnée Invalide
What is your cup size?	Donnée Invalide
Have you had breast cancer before?	Ye NoI don't know Donnée Invalide
Have you had history of breast cancer in the family?	YesNoI don't knowMember of family Donnée Invalide
Have you had mammogram?	YesNo Donnée Invalide
If yes, when?	Donnée Invalide
What was the outcome?	OKOther Donnée Invalide
If other, please write it down	Donnée Invalide
	Medical history
Do you have any allergies?	Donnée Invalide
If yes, what are they?	Donnée Invalide
Do you suffer from high blood pressure?	YesNoI don't know Donnée Invalide
Do you have diabetes ?	YesNoI don't know Donnée Invalide
Do you suffer from cholesterol?	OuiNonJe ne sais pas Donnée Invalide
Do you suffer from blood problems?	YesNoI don't know Donnée Invalide
Do you suffer from anaemia?	YesNoI don't know Donnée Invalide
Have you gone through depression?	YesNoI don't know Donnée Invalide
Do you suffer from breath problems?	YesNoI don't know Donnée Invalide
Are you currently under any treatment?	YesNoNot any more Donnée Invalide
Are you allergic to any medicines?	YesNo I don't know Donnée Invalide
Do you have any allergies?	YesNoI don't know Donnée Invalide
If yes, what are they?	Donnée Invalide
Have you had surgical procedure before?	YesNoI don't know Donnée Invalide
If yes, what are they?	Donnée Invalide
Other medical information?	Donnée Invalide
	Your quest for self-improvement can be achieved in many ways. Choosing surgery is one. I will help you achieve a clear understanding of the decision you are about to make. When you agree that you are making the correct choice, we can organize your trip.