For a medical questionnare please email sales@beautifulbeings.co.uk

An example of our Medical questionnaire
Full Name  
Address  
Phone  
Mobile Phone  
E-mail Address  

Note: Mobile numbers may be given to the clinic so that they may contact you once you arrive in Prague.

Date of Birth  
Sex Female Male

Procedure Required - please give details of the procedures that you would like to be carried out:

Please answer the following questions:

Have you been diagnosed with Hepatitis A, B, or C? YES  NO
Are you HIV Positive? YES  NO
Do you smoke? YES  NO
 - How many per day?  
Have you had any serious illness, disease, or injury? YES  NO
 - If yes please give details:
 
Have you ever undergone any operations with General Anaesthetic?		 YES  NO
 - If yes please give details:
 
Have you ever received local anaesthetic?		 YES  NO
 - If yes please give details and state if there were any complications:
 
Are you currently taking any prescribed medication?		 YES  NO
 - If yes please state the name of the medicine and why it was prescribed:
 
Are you being treated for any illness or disease?		 YES  NO
 - If yes please give details:
 
Are you allergic to any drugs?		 YES  NO
 - If yes please give details:
 
Do you suffer from any of the following conditions?
High blood pressure YES  NO
Heart palpitations YES  NO
Diabetes YES  NO
Blood clotting problems YES  NO
Heart disease YES  NO
Breathing or Lung problems YES  NO
Over-active thyroid YES  NO
Under-active thyroid YES  NO
Breast problems YES  NO
 
Please give details to any other medical conditions that you have had:
 
Please answer the following:
What is your age?    years
What is your height?    cm's
What is your weight?    kg's
Do you have a healthy lifestyle? YES  NO
Do you take regular exercise? YES  NO
Are you pregnant or planning to be in next 6 months? YES  NO
Are you taking any hormonal contraception or substitution? YES  NO
 - If yes please specify what drug and the reason for taking:

This document is sent directly to the clinic so that they have your correct details, so please be truthful. The information contained in the document is strictly confidential. Should you require a procedure after three months of completing this form, you will have to complete a new questionnaire. These forms are only valid for three months.

 
Client questionnaire

We have included this Client Questionnaire so that we may have an overview of your preferences, should you wish to undertake a procedure. This will help us give you an accurate quote, and make any arrangements more efficiently.

We would be very grateful if you could complete this form along with the Medical Questionnaire.

Procedure Wished
Would you like Beautiful Beings to
 - Arrange your transfer to/from Prague Airport? YES  NO
 - Arrange your accommodation for you? YES  NO
Would you like to bring a Partner/Friend? YES  NO
Which airport would you prefer to fly from?
Which date would best suit you for surgery?
{This date cannot be guaranteed, but we shall try to get you the closest date possible)

 


I hereby undertake that the information given in this questionnaire is correct and that I have read and understood and agreed to the Terms & Conditions enclosed.

TO PROVIDE THE SURGEONS BETTER INFORMATION PLEASE SEND US PHOTOGRAPHS OF THE PROCEDURAL AREAS BY E-MAIL, OR POST THEM TO US.