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First Name *

Last Name *

Date of birth

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Passport

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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?

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?

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)

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?