COSMETIC SURGERY TUNISIA - PLASTIC SURGERY TUNISIA

PRE- CONSULTATION FORM

Thank you for visiting Wissem surgery 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 23 165 764

Skype :

E-mail : info@wissemsurgery.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 *

PRE- CONSULTATION FORM Thank you for visiting Wissem surgery 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 23 165 764 Skype : E-mail : info@wissemsurgery.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 *