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Phone Personal Information First and Last Name * Country * Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia, Plurinational State of Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia, the former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Réunion Romania Russian Federation Rwanda Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela, Bolivarian Republic of Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Date of Birth * Sex * Male Female Cell No * Province * Please Select Gauteng Free State Kwa-Zulu Natal Limpopo Mpumalanga North West Province Western Cape Eastern Cape Northern Cape International Weight * Email Address * Town/Suburb * Height * Can we communicate with you via WhatsApp? * Yes No Medical and Surgical History Brief Medical History. Please list all significant illnesses. (Write none if not applicable) * Past Surgical History - Incl. plastic surgery (Write none if not applicable) Any issues with Anaesthesia in the past? (Write none if not applicable) * Allergies to medicines, food or other? Please provide further details. (Write none if not applicable) * Have you ever suffered from severe illness (Heart disease, diabetes etc)? If yes, please provide further details. * Are you prone to bruising or bleeding? * Yes No Do you have a family history of Heart Disease, Diabetes or High Blood Pressure? * Which of the following treatments are you enquiring about? Im enquiring about1 Liposuction Body Sculpting Fat Transfer - Face Fat Transfer - Body Tissue Fillers & Injectables Im enquiring about2 Non-Surgical Rhinoplasty Embedded Threadlift - Face Trampoline Neck-Lift Wellness & Weightloss Laser Skin Resurfacing Im enquiring about3 Active Acne & Acne Scarring Ageing Skin Pigmentation & Sun Damage Sagging Skin Rosacea Im enquiring about4 Spider Veins - Face & Body Cellulite or Stretchmarks Sagging Skin Chemical Peels Laser Hair Removal Medication, Lifestyle and Exercise Have you had any blood tests done recently - If yes, please provide date and laboratory used (Less than 3 months) * Please list all your prescription medications. (Write none if not applicable) * Please list all your NON-prescription medications. (Supplements/vitamins) (Write none if not applicable) * Do you Smoke Cigarettes? Please indicate how many per day * Yes No Do you drink Alcohol? Please indicate how much per week * Yes No Current level of Exercise * Sedentary (None) Low (Some activity) Moderate (Relatively Active) High (Very Active) What kind of exercise do you normally do? Photos and Acknowledgement Please confirm whether you are attaching photographs to this message * Yes, I am attaching Photographs No, I am not attaching Photographs Please Note In order for us to do a proper assessment - it is strongly advised that you include photographs to this enquiry. Upload your images Add Files What if I am not based near The Face and Body Place? A consultation with our doctor is required to evaluate your requirements and overall health status. We will then guide you with recommendations and a treatment protocol suited to your needs. We offer on-site consultations as well as virtual consultations (Zoom, Skype, WhatsApp or by telephone) no matter where you reside. Consultation Preference: * On-site Skype Zoom Whatsapp What will Treatments cost me? At the time of consultation, we will assess your requirements and provide a quotation for treatments, products and any ancillary costs. Our administrative team can also assist with financing options if these are required. You may click here to be redirected to the MediFin web page. MediFin offers financing options that may suit your needs. Final Comments / Questions * I hereby acknowledge that the information provided within this document is true and correct at the time of completion. For a detailed assessment and recommendations, a consultation at our clinic is ideal. Skype consultations for out of town patients will be considered and guidance given for potential assistance. * Accept Decline
