Cosmetic Surgery Treatment India,Cosmetic Laser Surgery India,Cosmetic Surgery Treatment Delhi,Cosmetic Laser Surgery Delhi

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cosmetic surgery treatment India, cosmetic laser surgery India

AMERICAN PLASTIC SURGERY, SKIN, DENTAL AND WELLNESS INSTITUTE

cosmetic surgery treatment Delhi, cosmetic laser surgery Delhi


		SERVICES Cosmetic Surgery Anti Aging & Skin Rejuvenation Advanced Laser Treatment Stress Relief & Pain Management Body Contouring Customized Wellness Packages Lunch Time Sessions

APPOINTMENT

Maintaining your confidentiality is very important to us. To ensure your privacy, consultations and treatments are scheduled by appointment only. We request you to fill out this brief form and send it to us at the MedSpa. This will help us to expedite making your appointment. The patient Health History form is required for all our INTERNATIONAL PLASTIC SURGERY / INTERNATIONAL COSMETIC SURGERY / MEDICAL TOURISM PATIENTS.

(* represents compulsory fields )

*Your Name :

Sex :

Date of Brith :

*Email Address :

Address :

City :

State/Province::

Zip/Postal Code :

*Country :

Phone Number (Include Country Code/Area Code) :

Occupation :

*Your Reason for a MedSpa Appointment?

*What specifically are your objectives and concerns?

WHEN WOULD YOU LIKE US TO SCHEDULE YOUR APPOINTMENT?
Month:

WE WOULD LIKE YOU TO FILL OUT THE FOLLOWING HEALTH HISTORY FORM TO ENEABLE US TO DO OPTIMUM PLANNING FOR YOUR TREATMENT

Do you have any health /skin problems?

Yes No

Have you had any major surgery?

Yes No

Have you had any cosmetic surgery or skin treatments?

Yes No

Have you any major injuries?

Yes No

Do you take any medications/nutritional supplements/herbal medications/ cosmesceuticals?

Yes No

Have you ever had any adverse reaction to local or general anesthesia?

Yes No

Do You take Aspirin/Blood Thinners?

Yes No

Have you had an allergic reaction to medication/cosmetics?

Yes No

Do you have any other allergies?

Yes No

Do you have any bleeding problems?

Yes No

For each answer "YES" to any of the questions above, please elaborate by describing your reasons why.

Do you smoke?
If Yes, how much?

Do you take alcohol or other recreational medicines/drugs?
If Yes, please describe:

Are You Pregnant / Lactating?

Yes No

Do you have any children?
If Yes, how many, and how old is the youngest?

Use of Skin Foundation / Moisturizers / Other cosmetics.
If Yes, which one?

Exercise/Yoga/ biking/ weights/other significant lifestyle

Yes No

Do you have excessive exposure to sun?

Yes No

Do you have work related stress?

Yes No

Do you have muscle aches and pain?

Yes No

Are you close to your ideal weight?

Yes No

We are available

2A/2, Taj Appartments,
Rao Tula Ram Marg,
Sector - 12, R.K. Puram,
New Delhi - 110022
Mob : +91-9818369662 / 9810700036 / 9958221981 / +91-26109898 / 26187792 / 26187793

9:30 am to 5:30 pm Monday to Friday

9:30 am to 1:30 pm Saturday

Sunday Off

*Enter the code shown on image:

YOUR CONFIDENTIALITY AND COMFORT IS OUR PRIORITY

Our Services

Cosmetic Surgery | Anti Aging & Skin Rejuvenation
Advanced Laser Treatment | Stress Relief & Pain Management
Body Contouring | Customized Wellness Packages