Dr Harris Zavrides

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First Name:

Last Name:

Birth day:

Birth month:

Birth year:

Gender:

Telephone:

Fax:

Mobile:

Email:

(E-mail)

Passport number:

Postal code:

Country:

Occupation:

Next of kin details, to be contacted in case of emergency only

First name:

Lastname:

Relationship:

Contact number:

How did you hear about “Harris Zavrides Plastic Surgery Center”?

Please answer the following questions fully.The information is treated as strictly confidential and is necessary to insure that the key health aspects are considered prior to your consultation in Cyprus. Plastic Surgery is a serious Surgical Procedure.

How would you say your skin heals?

If you smoke how many a day?

Do you have a smokers cough?

How is your general health?

What is your blood group?

Does your religion prohibit you from having a blood transfusion in the unlikley event that you may need one?

Are you being treated or have you been treated for any of the following?
If yes or no, past or present, please select appropriate boxes, give full details and list medications prescribed in the details section further down the form.

Anaemia:	Yes No	Diabetes:	Yes No
Asthma:	Yes No	Drug dependance:	Yes No
Contraceptive pill:	Yes No	Epilepsy:	Yes No
HRT Hormone Replacement:	Yes No	Eye problems eg dry eyes glaucoma:	Yes No
Blood pressure:	Yes No	Heart problems:	Yes No
Breathing problems eg Bronchitis Chronic cough:	Yes No	Jaundice:	Yes No
Deep Vein Thrombosis Blood Clots:	Yes No	Stroke:	Yes No
Depression:	Yes No	Phlebitis:	Yes No

Any other conditions not mentioned above and further details
including medications for the ones you did list::

Do you have any allergies associated with foods medication
surgical tape elastoplast:

Have you had ANY surgical procedures before that required
you to have a general anesthetic? If yes, please supply full details:

Have you ever had any negative reactions to local or
general anesthetics? If yes, please supply full details:

Any keloids or bad scarring:

Yes

Ever had a blood transfusion? If yes please give full details:

Breast Surgery

When was your last mammogram and what was the result?

Has any family member suffered from breast cancer?
If yes, please supply details:

Have you had any breast lumps cysts? If yes please supply details:

If it were found to be necessary would it be possible to
discuss your medical history with your GP As cosmetic surgery is an
elective procedure we would only contact him her directly
with your express permission:

Yes No (If yes please supply GP details below)

Full Name::

Telephone:

Choice of Surgical Procedure(s)

Abdominoplasty tummy tuck:		Laser skin resurfacing:
Breast augmentation:		Liposuction Lipoplasty:
Breast ift:		Lip augmentation:
Breast reduction:		Rhinoplasty (Nose surgery):
Ear surgery (Otoplasty):		Botox:
Eyelid surgery:		Fat transfer:
ForheadBrow lift:		Filler:
Face Lift surgery:		Mesotherapy:

Heght in meters:

Heigh in feet:

Weight in tkg:

Weight in tlb:

Preferred Accommodation Details:

Preferred Diet:

Arriva lyear:

Arrival month:

Arrival day:

Have you read our terms and conditions?

Yes No

Additional Comments?

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