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Medical Questions

Please read carefully and answer all Questions

Date:

* Surname:

* First Names:

* Email:

* Please Re-Enter your Email:

* Home Telephone:

Contact Telephone:

* Postal Address:
   (House No and Street)

* Postal Address:
   (Town or Suburb)

* Postal Address:
   (Country, Area and Province)

*  Postcode / Zip:

Have you visited South Africa before:

Yes No

How did you find NuLook Surgery:

Please Specify Procedure you are considering:

Date of Birth:

Day

Month

Year

Occupation:

Name & Address of GP:

Medical History

Please Read Carefully and Answer All Questions

Type of Procedure Required:

Do you suffer from or have a History of:

Heart Disease:

Yes

No

High Blood Pressure:

Yes

No

Epilepsy:

Yes

No

Any Other Serious Illness:

Yes

No

If Yes, Please Give Details:

Is your Family Prone to certain Diseases:

Yes

No

If Yes, Please Give Details:

Yes

No

Please Indicate & Give Details of:

Smoker:

If Yes, How many Cigarettes Per Day:

Pregnant/Breast Feeding:

History of Fever Blisters:

Cortisone:

Medicine for High Blood Pressure:

Antibiotics:

Roaccutane:

Antocoagulants:

Details of Other Medication:

Do you have Any Allergies eg: Penicillin:

Yes

No

If Yes, What:

How many Pregnancies have you had:

Have you had any C-Sections:

Yes

No

If Yes, Please Specify Procedure and Approximate Dates:

Have you had Cosmetic Surgery before:

Yes

No

If Yes, Please Specify Procedure and Approximate Dates:

Please Specify Any Other Information:

Height:

Weight:

Please have Current Photographs of yourself prepared and be ready to make these available.

Please Specify your preferred type of Accommodation:

Period being considered for Travel:

Loan Required :

Enquiry:

* I have read the Terms and Conditions:

   Terms and Conditions

By Submitting the above form you have Agreed to the Terms and Conditions.