Aesthetic Tunisia
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Chirurgiens plasticiens
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Interventions esthétiques
Les hotels

Free estimate :

 

Civility


Name :

First Name :

Date of birth :
Profession :
   
   
Adress :
Postal Code:

Town :

Country :

Tel. :

Fax :

Mob. :

Email :

When can we call you?

Do you have a Skype/MSN acount:

Which is your acount:
   
Medical Infomations
General Informations
Age :
Hight in cm : cm
Weight en kg : kg
Smoking :
Number of cigarettes per day :
You smke since how many years
Particular family antecedents ( like cancer for breast operations)
What kind?
Your intervention  
Among the following list, which intervention do you want to profit:
Choice :
Face
1. Otoplasty
2. Botoxes
3. Injectable fillers
4. Mesolift
5. Ccomplete lifting
6. Lifting + neck
7. Face feminizing

Eyelid surgery
8. Blepharoplasty : 2 eyelid
9. Blepharoplasty : 4 eylid

Nose surgery
10. Rhinoplasty

Dental Surgery
11. Tooth whitening
12. Ceramic crowns
13. Dental establishment

• Body
14. buttocks
15. Abdominal Lipoaspiration + hight
16. Abdominal apron + buttocks
17. Only Abdominal apron
18. arms/thighs lifting

• Breast
19. Breat reduction
20. Breast augmentation
21. Breast lifting

Hair
22. Hair transplants
   
Si vous désirez bénéficier d'une augmentation mammaire, précisez la taille actuelle de votre bonnet de soutiengorge ainsi que la taille désirée:
Current size :
Size wished:
Medical and surgical antecedents
Do you have allergic antecedents??
If Yes, with which drugs or products are you allergic ?
Do you have cardiovascular antecedents ?
If yes, specify :
Treatment in progress :
Are you diabetic?
if Yes, are you under treatment ?
Specify your treatment :
Last value of glycemia :
Are you treated for a particular affection?
If yes, specify :
Are you treated for another pathology? Thank you to specify all your treatments in progress (aspirine, pills…)
Treatment 1 :
Treatment 2 :
Treatment 3 :
Already profited of a plastic surgery intervention ?
If yes what type of intervention ?
Which year ?
Have already undergoes a surgical operation (other than plastic surgery) ?
 
If yes what type of intervention ?

Which year ?

Your Stay  
ENSURE THAT YOUR PASSPORT STILL VALID
 
When do you consider your intervention ?
First period :
Second period :
Third period :
Do you wish a stay including hotel ?
Which hotel do you want ?  
                      Stay (FB, HB) :
                      Room (single, double) :
                      Number of adults :
                      Number of childrens :
                      Childen's age:
Do you wish to profit from particular activities during your stay (spa, excursions…)
 
 

To receive your personalized estimate and the opinion of our surgeons, do not forget to join photographs of face and profile of the concerned area .

   

 

 

 

 

 

 

 

 

 

 

Fill the form with request for free estimate and profit from a free consultation.

Our plastics surgeons wil quickly consult and study your ask.
An adviser will call you to explain you the steps necessary to your operation and the necessary recommandantions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
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