MEDICAL INFORMATION FORM

PERSONAL DETAILS

 
      

Please note: Smoking can cause delayed recovery, wound breakdown and increased risk of infection. We strongly recommend that you stop smoking 4 weeks before and 4 weeks after surgery. You may be denied surgery if you smoke and the ABA Guarantee is void for smokers.

 

FAMILY MEDICAL CONDITIONS

 
         
         
         
         
         
 

PERSONAL MEDICAL CONDITIONS

 
         
         
         
         
         
         
         
         
         
         
         
         
         
    
    
    
         
    
    
         
         
         
         
    
    
    
         
         
    

Please mark the conditions below you have had (or currently have) or received treatment for now or in the past.

Do you feel that any of the conditions you have indicated have had an impact on yourself image and your decision to choose cosmetic surgery?   

 

HABITS

 
    
    
 

WOMEN

 
    
         
    
    
 

GENERAL QUESTIONS

 
    
    
    
    
    
    
    
 

ACCEPTANCE & ACKNOWLEDGEMENT

 

Are you prepared to help your health in recovery so that risks are lower and results are better eg. give up smoking 4 weeks before and 4 weeks after surgery, stay out of sun, purchase cremes to help in scar reduction, eat well and exercise?     

I have read, understand and       to ABA Terms & Conditions and Assistance Guarantee Policy/Shared Responsibility & Care.

**electronic signature or text insertion of name is deemed as signing

Terms & Conditions Assistance Guarantee