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Medical History Form

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Medical History Form

Medical History Form

Please fill the medical history form below. After it is evaluated and approved by the surgeon and anesthesiologist, you can proceed to book your treatment.

Full Name (required) :

Your Email (required) :

Phone number including country code (required) :

Country (required) :

Date of Birth (required) :

Weight in kilograms (required) :

Height in cm (required) :

What is your blood type? (required) :

Do/Did any of these Medical Problems apply to you? Please select yes of those that do/did.

Heart Disease (required)

Yes No

High Blood Pressure (required)