Your Name And Surname (Necessary)
E-mail address (Necessary)
Your Phone Number (Necessary)
Your age
Height (as cm)
Your weight (kg)
What Plastic Surgery do you want to have? (Necessary)
Do you have a hereditary disease? (Necessary) YesNo
If yes, explain your illness
Do you take any medication all the time? (Necessary) YesNo
If the answer is yes, write down the medication(s) you are using
Do you have a chronic illness? (Necessary) YesNo
Are you a smoker? (Necessary) YesNo
If yes, explain how much you use
Did you give birth? (Necessary) YesNo
Are you planning on getting pregnant again? (Necessary) YesNo
Do you breastfeed? (Necessary) YesNo
Any concerns about the surgery? (Necessary) YesNo
If yes, please explain your concerns
