Medical Quote

Civility(*)

Mrs.

Sir

Entrée non valide

First name(*)

Veuillez saisir votre prénom

Last name(*)

Veuillez saisir votre nom

Email(*)

Veuillez saisir une adresse Email Valide

Phone

Entrée non valide

Adress

Entrée non valide

Pays(*)

Veuillez saisir un votre pays de résidence

Profession

Entrée non valide

family doctor or your general practitioner

Entrée non valide

Date of birth(*)

Entrée non valide

Weight (Kg)(*)

Entrée non valide

Height (cm)(*)

Entrée non valide

BMI Body Mass Index

Entrée non valide

Your consumption habits

Do you smoke ?

Yes

Entrée non valide

number of cigarettes per day:

Entrée non valide

Do you drink alcohol?

Yes

Entrée non valide

Your daily consumption of alcohol

Entrée non valide

Do you take anticoagulants?

Yes

Entrée non valide

Do you take aspirin or likewise?

Yes

Entrée non valide

Do you take multivitamin, gingko, ginseng, omega 3?

Yes

Entrée non valide

Do you take any supplement or plants to loose weight

Yes

Entrée non valide

anti-inflammatory (voltarene, ibuprofen)

Yes

Entrée non valide

Do you have children?

Yes

Entrée non valide

Number of children

Invalid Input

Date of birth of last child

Entrée non valide

When did you stop the last breastfeeding ?

Entrée non valide

Would you like to have children in the next two years ?

Yes

I don't know

Entrée non valide

Medical history

Other diseases

Entrée non valide

Do you have heart disease?

Yes

Entrée non valide

What kind of heart disease?

Entrée non valide

Do you have respiratory diseases?

Yes

Entrée non valide

What are respiratory diseases?

Entrée non valide

Have you been intolerant of drugs (antibiotics for example)?

Yes

Entrée non valide

Quels sont les anti-inflammatoires que vous consommez ?

Entrée non valide

anti-inflammatoires (voltarene, ibuprofen)

Yes

Entrée non valide

What allergies do you have to medication?

Entrée non valide

Do you take medication regularly?

Yes

Entrée non valide

What medications do you take?

Entrée non valide

Have you ever had local anesthesia (including the dentist)?

Yes

Entrée non valide

Did you have any reaction to this anesthesia?

Yes

Entrée non valide

Do you tend to heal badly?

Yes

Entrée non valide

Do you tend to bleed easily or bruise or bruise?

Entrée non valide

Have you had any surgery(s)?

Yes

Entrée non valide

What surgeries have you had?

Entrée non valide

Do you have a personal or family history of thrombophlebitis or pulmonary embolism?

Yes

I don't know

Entrée non valide

Specify the reason, the date, the treatments

Entrée non valide

Have you had any blood transfusions?

Yes

Entrée non valide

Specify reason and date

Entrée non valide

Desired surgery

Please check at least one or more of these boxes.

If none of these choices suits you, tick "other" and fill in the field "Other intervention"

Breast Surgery

Other intervention not listed

Yes

Non

Entrée non valide

Other intervention

Entrée non valide

In order to process your request, it is essential to attach photos of the areas you wish to process.

You can also include photos of desired results.

For more information on how to take photos, please follow this guide Guide to take photosHow to take pictures

Photo

Entrée non valide

Photo

Entrée non valide

Photo

Entrée non valide

Photo

Entrée non valide

Photo

Entrée non valide

Photo

Entrée non valide

What is it that bothers you or that you want to change in your physique?

Commentaires

Entrée non valide

Medical Quote

Free Quote

Medical Quote

Free Quote