PRE- CONSULTATION FORM
Thank you for visiting TUNISSURGERY website .
To be able to respond to your application in a clear, precise, and detailed manner, please fill out all the fields in every stages of the following form.
In addition to this form, you will have to send us the required pictures.
R equired p hotographs :
For body surgery
Body photographs of Front, Back and Profile.
For Face surgery
Face photographs of Front and Profile – both sides.
These pictures are essential for our surgical team to be able to establish a clear and accurate preliminary medical diagnosis.
We will be pleased to respond to you as quickly as possible.
Important : Only those including the required photographs and the Motivation Letter will be examined by our team.
A ll the information you supply to us will be treated with the strictest confidentiality. |
Phone: 00 216 24 119 646
Skype :
E-mail : info@tunissurgery.com
Or If you would like to get started, please fill in the online consultation form below : |
| Your personal Details: |
| Name *: |
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| Surname *: |
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| Gender (M, F) * |
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| Date of birth *: |
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| Weight *: |
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| Height *: |
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| Address *: |
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| Tel *: |
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| Post code *: |
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| Email address *: |
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| Date ( d / m / y ) *: |
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To |
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| secret question *: |
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| secret answer *: |
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| Which surgery or treatment is required: |
Orthopaedic Surgery *:
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Cosmetic Surgery * :
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| For cosmetic surgery please attach photographs ( front and the two sides : right and left) of the area of your body to be treated. |
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General surgery *:
Please type in the name of the required procedure |
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| General Medical history : |
| Do you smoke * |
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| If yes, how many cigarettes per day |
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| Do you drink alcohol * |
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| If yes, how many units per day? |
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| Do you suffer from any allergy to medication, food or any other products * |
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| If yes , please list them. |
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| Do you suffer from diabetes . * |
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| Do you suffer or ever suffered from asthma, pneumonia or bronchitis? * |
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| If yes, specify. |
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| Do you have any heart condition ? * |
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| If yes specify |
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| Do you suffer from high blood pressure ? * |
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| If yes what medication are you taking ? |
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| Do your suffer from kidney disease * |
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| If yes specify : |
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| Do you suffer from liver or spleen disease * |
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| If yes specify |
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| Do you suffer from any disease not mentioned here ( Y,N) * |
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| If yes specify |
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| Have you had any surgery in the past * |
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| If yes, specify kind of surgery and when? |
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| Have you had any reaction to anaesthetic in the past * |
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| If yes, specify the kind of reaction |
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| Are you taking any medication * |
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| If yes, list your medication here. |
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| Questions you would like to ask your surgeon |
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| Comments : |
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Fields compulsory *
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