Book Your Beauty First Name * Last Name * Date of birth Gender Select GenderMaleFemale Telephone * Fax Mobile Email * Passport Postal Code Country Next of kin details, to be contacted in case of emergency only First Name Last Name Relationship Contact No How did you hear about “Harris Zavrides Plastic Surgery Center”? Please answer the following questions fully.The information is treated as strictly confidential and is necessary to insure that the key health aspects are considered prior to your consultation in Cyprus. Plastic Surgery is a serious Surgical Procedure. How would you say your skin heals? If you smoke how many a day? Do you have a smokers cough? YesNo How is your general health? What is your blood group? Does your religion prohibit you from having a blood transfusion in the unlikley event that you may need one? YesNo Are you being treated or have you been treated for any of the following? If yes or no, past or present, please select appropriate boxes, give full details and list medications prescribed in the details section further down the form. Anaemia YesNo Diabetes YesNo Asthma YesNo Drug dependance YesNo Contraceptive pill YesNo Epilepsy YesNo HRT Hormone Replacement YesNo Eye problems eg dry eyes glaucoma YesNo Blood pressure YesNo Heart problems YesNo Breathing problems eg Bronchitis Chronic YesNo Jaundice YesNo Deep Vein Thrombosis Blood Clots YesNo Stroke YesNo Depression YesNo Phlebitis YesNo Any other conditions not mentioned above and further details including medications for the ones you did list Do you have any allergies associated with foods medication surgical tape elastoplast: Have you had ANY surgical procedures before that required you to have a general anesthetic? If yes, please supply full details: Do you have any allergies associated with foods medication surgical tape elastoplast: Any keloids or bad scarring: YesNo Ever had a blood transfusion? If yes please give full details: Breast Surgery When was your last mammogram and what was the result? Has any family member suffered from breast cancer? If yes, please supply details Have you had any breast lumps cysts? If yes please supply details If it were found to be necessary would it be possible to discuss your medical history with your GP As cosmetic surgery is an elective procedure we would only contact him her directly with your express permission: YesNo Full Name Telephone Choice of Surgical Procedure(s) Abdominoplasty tummy tuck Laser skin resurfacing Breast augmentation Liposuction Lipoplasty Breast ift Lip augmentation Breast reduction Rhinoplasty (Nose surgery) Ear surgery (Otoplasty): Botox Eyelid surgery Fat transfer ForheadBrow lift Filler Face Lift surgery Mesotherapy Height in meters Height in feet Weight in tkg Weight in tlb Preferred Accommodation Details Preferred Diet Arrival Date Have you read our terms and conditions? YesNo Additional Comments?