LABIAPLASTY

Name

First

Last

Email *

Phone

Please answer the medical questions below to complete your assessment;

1. Have you ever had surgery before? *

2. If yes, please provide further details *

3. If yes, when and what was the procedure? *

4. Do you have any children? *

5. If yes, how many and when were they born? *

6. Are you a smoker? If yes, how many per day? *

7. Are you currently breastfeeding ? *

8. Is there any chance that you could be pregnant? *

9. Are you currently on any form of birth control? If yes, please specify and indicate whether it contains oestrogen. *

10. Are there any health concerns that we should be aware of? If yes, please specify. (for example, thyroids, hepatitis, tuberculosis, high/low blood pressure) *

11. Are there any hereditary health concerns that we should be aware of? If yes, please specify. (for example, hepatitis, heart disease, sickle cell anemia) *

12. Do you have any allergies? If yes, please specify. *

13. Do you use or take illegal substances? If yes, please specify and indicate the last time you used. *

14. What is your current weight? *

15. What is your current height? *

16. How old are you? *

17. Do you have any upcoming surgeries or procedures [medical or not] that we should be made aware of? *

18. Are you currently taking any medication? *

19. If yes, what medication are you taking? *

Notes

To complete your online assessment, please do send us your personal images as requested below; (Please do not wear any clothing except underwear.) A full image of the FRONT-BACK-LEFT-RIGHT sides of your body with your arms relaxed by your side

Please notify us if any change occurs after you have submitted your images and personal details.

Please wait while your file is being uploaded *

Click or drag files to this area to upload. You can upload up to 4 files.

Max File Size 50 Mb.

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