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

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