Medical Form | Luviacure

Patient Medical History Form

What is your name and surname?

What is your age?

What is your gender?

Male

Female

What is your height?

What is your weight?

Expected Operation Date?

Do you have any chronic illnesses? If yes, please write them below.

Have you had any surgeries before? If yes, please write them below and indicate dates.

Do you use any medications currently or recently stopped? (including aspirin and non-prescription)

Do you take vitamins or herbal supplement? If yes, Please write them below.

Please write all your drug allergies (incuding latex)

Do you smoke? If yes How long and how many do you smoke per day?

Do you drink alcohol? If yes, How often?

If Rhinoplasty
Please answer the following questions;

Is it going to be your first rhinoplasty?

Have you injured your nose before?

Do you snore?

What are your complaints mainly?

By checking the checkbox and pressing the "Submit" button, you explicitly grant permission for the sharing of data you have provided with the relevant professionals. You confirm that the process has been initiated according to your request, and you have read and understood the Luviacure Terms And Conditions and Privacy Policy

Thank you for submitting your medical form.

We have received your information successfully. Our team will review your details and contact you shortly.

Patient Medical History Form

If Rhinoplasty Please answer the following questions;

Contact Us

If Rhinoplasty
Please answer the following questions;