Harmonia Surgical Tourism Istanbul
Harmonia Surgical Tourism - For Appointments: Istanbul +90 (212) 465 6071 / UK +44 20 3290 0005
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Medical History Form

Please fill in the Medical History Form for your medical consultation.

Fields marked (*) are compulsory

Choice of Medical Treatment
Aesthetic Plastic Surgery
Laser Assisted Surgery
Laser Assisted Non-surgical Procedure
Cosmetology
Bariatric Surgery
Cosmetic Dentistry
Reconstructive Plastic Surgery
 

Contact Details

Full Name*  
Address*  
Post Code*  
Country*  
Phone Number    
Mobile Number    
Email Address*  
Best times to call    
Which date would best suit you  
for surgery?  
 
Date of Birth      Pick a date
Your height    
Your weight    
 

Medical History

 
Allergies  Yes  No
 
Anaemia  Yes  No
 
Asthma  Yes  No
 
Blood pressure  Low  High  Fine
 
Deep Vein Thrombosis/
Blood Clots
 Yes  No
 
Depression  Yes  No
 
Diabetes  Yes  No
 
Drug dependance  Yes  No
 
Heart problems  Yes  No
 
Hormone replacement  Yes  No
 
Jaundice Yes  No
 
Additional information
 
Any other condition not mentioned?
 
Any other medications?
 
Any local or general anaesthetic problems?
 
Any keloids or bad scarring?
 
Describe your personal desires and aspirations for the outcome of your procedure(s)
 
If you have any further questions or requests please supply details
 
Terms and conditions

By sending Harmonia the filled patient medical form, I am confirming I have understood the terms and conditions and that a valid legal agreement is in place.

I agree to pay the deposit to Harmonia once arrangements are put in place for an initial consultation. Full Information will on be shared on receipt of the deposit, which isalready advised by Harmonia in writing to me.

Patient Medical Form
  • By returning this filledmedical history form and the photos (1 front and 1 side views if not asked more) I agree to let Harmonia and my assigned doctor use this form for the purposes limited to medical use only

  • Harmonia confirms that all the information in the form will be treated in a discrete and confidential way. None of the information I provide to Harmonia for the purpose of the treatment will be used in the future without my written permission

  • If I have failed to disclose any previous surgery or important medical information in my medical questionaire then I indemnify fully all parties involved in the facilitation of this Surgery from any complications that may arise by virtue of my non disclosure
Other circumstances

As being The client, I am fully responsible for mysafe arrival to Istanbul.

I have fully read and understand all the Terms & Conditions and I agree to same
 
  

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