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Medical Questionnaire

Information enclosed in Medical Questionnaire are essential for our consultant surgeons to make a proper assessment. They will analyse your case and make a suggestion of what would be the best way to reach the best result for you.

Do not hesitate and fill in our Medical Questionnaire and submit it along with your photos of a particular area you wish to have treated. The best aspects for the photos are from the front and side. Once we receive them we will be able to provide you with the medical assessment within 48 hours. At the same time we´ll give you the exact price of your treatment package including accommodation and all transits. We can assure you that our prices are accurate and hide no extra charges.

    Contact Details
    Personal Information
    Sex : MaleFamale


    Date of birth
    Choice of Surgial Procedure(s)
    Medical Historiy
    Allergies : YesNo
    Anaemia : YesNo
    Asthma : YesNo
    Contraceptives : YesNo
    Blood pressure : YesNo
    Depression : YesNo
    Diabetes : YesNo
    Drug dependance : YesNo
    Heart problems : YesNo
    Hormone replacement : YesNo
    Jaundice : YesNo
    Psychiatric illness : YesNo
    Additional Information
    Does your religion prohibit you from having a blood transfusion in the event that you will need one? YesNo
    Do you smoke? YesNo
    How much alcohol do you drink? NoneDailyOccasionally
    Attach Photos Of The Areas You Wish To Have Treated
    Photo 1 :
    Photo 2 :
    Photo 3 :
    Photo 4
    Photo 5

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    I hereby give consent according to article 6.1 (f) Regulation GDPR and paragraph 13 1 (a) act no. 18/2018 with regard to the protection of personal data, processing and storing of my personal data to Essi Cosmetic Surgery, for the communication purposes. I give my consent to my personal data in extent of: name and surname, email address and phone number.
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    I agree to receive offered news, discounts, bonuses and other benefits


    Essi Cosmetic Surgery All Rights Reserved 2018
    Essi Cosmetic Surgery is managed by NERA SOLUTIONS LTD - Registered in United Kingdom
    Company Number : 11700260

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