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  Enquiry Form

Medical Form

Photograph Making

 




  Tel.: +34 945 467 393
Fax: +34 971 254 686


   

 

 

Вся информация, которую Вы предоставляете, рассматривается в соответствии с правилами и положениями закона Испании о защите данных. Мы всегда относимся с уважением к Вашей частной жизни.

* Пожалуйста, заполните обязательные поля .
Medical Questions.
* Surname:
* First Names:
* Email:
Home Telephone:
* Contact Telephone:
* Postal Address: (House/Flat No and Street)
* Postal Address: (Town)
* Postcode / Zip:
* County/province:
* Postal Address: (Country)
Gender: male    female
Have you visited Mallorca before? no     yes
How did you learn about Mallorca medical Group?
Date of Birth:    Year:
Occupation:
Name & Address
of GP/house doctor:

Medical History.
In you own interest, it is essential you inform us accurately about your health.
Procedure/s of your choice
   Please Specify: (If Appropriate)
Do you suffer from or have a History of:
Heart Disease: no     yes
High Blood Pressure: no     yes
Epilepsy: no     yes
Any Other Serious Illness: no     yes
If Yes, Please Give Details:
Is your Family Prone to certain Diseases: no     yes
If Yes, Please Give Details:
Have you had any mamography: no     yes
If Yes, Please Give Details (when and Result):
Please Indicate & Give Details of:  
Smoker: no     yes (If yes, How many Cigarettes Per Day?)
Pregnant/Breast Feeding: no     yes
History of Fever Blisters: no     yes
Cortisone: no     yes
Medicine for High Blood Pressure: no     yes
Antibiotics: no     yes
Roaccutane: no     yes
Anticoagulants: no     yes
Aspirine or Salicylic acid containing medication: no     yes
Details of Other Medication:
Do you have Any Allergies eg: Penicillin: no     yes
If Yes, What:
How many Pregnancies have you had:
If so, how much weight you took in the heaviest one:
Have you had any Cesarean Sections: no     yes
If Yes, Please Specify Procedure and Approximate Dates:
Have you had Cosmetic Surgery before: no     yes
If Yes, Please Specify Procedure and Approximate Dates:
Please Specify Any Other Information:
Height:
Weight:
Do you have any earings/piercings? no     yes
Any scars on your body? no     yes
Where:
Preferred type of Package or accommodation:
Period being considered for Travel:                 From to
Loan Required? no     yes
Enquiry:
* I have read and accepted the Terms and Conditions:
 


 
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