This site can only give you general information  and is not intended to replace a person to person consultation.  However we would like to offer you our opinion about your specific request.  To help us, please fill out this form and send it back to us, either via fax.
	Elke Medical Secretary	Patricia Medical Secretary

 1. How can we help you?

 

 2. Personal details

 3. General condition

Cosmetic plastic surgery should be low risk surgery.  Therefore to give us a better idea of your current health condition please fill this in to the best of your abilities.

Are you permanently or temporarily on any sort of medication if so which sort and why.
 

 
Do you have any type of allergy, if so explain.
 

 
Do you currently have or have had any sort of serious medical conditions such as: surgeries, treatments, disease and if so explain.
 

 
Have you ever had any form of plastic surgery, if so describe.
 

How did you find the Wellness Kliniek website?