Book Now - ACare Sungreen

Title *Mr.Mrs.MissMs.

Last Name (as per passport) *

First Name (as per passport) *

Passport Country *

Nationality *

Preferred Language *

Date of Birth *

Gender *FemaleMale

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal code *

Country *

Phone *

Email Address *

Travel Companion/Emergency Contact

Travel Companion or Person To Contact In Case of Emergencies

First Name (as per passport)

Last Name (as per passport)

Date of Birth

Phone

Email Address

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal code

Country

Planned Date of Surgery *

Alternative Date of Surgery *

Please list them:

What results do you expect? (Please be as specific as possible):* *

Questions to surgeon *

Your height (cm) *

Your Weight (kg) *

Do you have a history of blood clots *UnsureYesNo

Do you take blood thinners *YesNo

Diabetes or blood sugar problems *YesNo

Heart problems *YesNo

Blood pressure problems *YesNo

Blood disorders *YesNo

HIV or AIDS *YesNo

Hepatitis B *YesNo

Neorologic problems *YesNo

Thyroid problems *YesNo

Lung problems *YesNo

Kidney or Liver problems *YesNo

Previous/current history of cancer *YesNo

Nervous Breakdowns/Depression *YesNo

Anesthesia problems *YesNo

Keliod Scarring *YesNo

If you have answered YES to any of the above, please specify:

Have you had or do you have any medical conditions not mentioned above? *YesNo

If yes, please specify:

Medical History

Have you been hospitalized or received medical care in the past 12 months? *YesNo

If yes, when?

If yes, what was the reason for this?

Have you had any surgery before? *YesNo

If yes, when?

If yes, what kind?

Do you have fillers, implants or any metal objects in your body? *YesNo

If yes, please specify what & when this was inserted/injected:

Do you have difficulty with healing or scarring? *YesNo

Do you have any allergies to food, drugs, etc? *YesNo

If yes, please specify:

List all medications you currently take including dosage for each:

List all vitamins or food/nutritional supplements you currently take:

Have you ever taken a MAO inhibitor such as Nardil, Marplan or Parnate? *YesNo

If yes, when was your last dose?

Have you ever taken an anticoagulant such as Coumadin, Heparin, or a daily Aspirin? *YesNo

If yes, when was your last dose?

Do you smoke? *YesNo

If yes, how much do you smoke?

If yes, when was the last time you smoke?

Do you drink alcohol? *YesNo

If yes, how much do you drink?

Do you have breast implants?YesNo

If Yes, please specify method

Are you on birth control? *YesNo

HRT Medications / Hormone Patch? *YesNo

Age of youngest child

Current bra size

Desired bra size

Desired placement of implants?Behind of muscleIn-front of muscle

Desired Implants?UnsureSalineSilicone Gel

Desired Incision?UnsureArmpitsUnder Breast CreaseLower edge of Areola

Have you had a mammogram?YesNo

Please specify results (patients over 40)

Are you pregnant now?YesNo

Are you planning for more pregnancies?YesNo

Date you last breastfed

Do you have monthly periods?YesNo

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