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Body Contouring Patient Form

Home/Body Contouring Patient Form

Body Contouring Patient Formdrnovikovaadmin2020-07-09T12:42:12+00:00

Body Contouring Patient Information

Surname *

Name *

Date Of Birth *

Email *

Phone *

Home Address *

Details of Current Employment

How did you hear about us?

Weight *

Height *

What area of the body would you like to address? *

What are your reasons for Body Contouring?

What are your expectations from Body Contouring?

Do you have cellulite?

Yes

No

If yes, where is it located?

Do you have any loose skin?

Yes

No

If yes, where is it located?

What medication are you taking? If any.

What supplements are you taking? If any.

Have you had medical illness in the past? If yes, please describe and provide details of treatment if any.

Please specify any chronic diseases you may have?

What allergies do you have? If any.

What surgeries have you had in the past including cosmetic surgery? Please state date of surgeries if applicable.

Please specify and describe if you have any significant family history?

Do you have any metal implants?

Yes

No

Do you have a pacemaker?

Yes

No

Please describe your exercise routine- duration, weekly frequency, intensity and type

Please describe your diet-breakfast, lunch, dinner, snack, drinks

Do you drink alcohol?

Yes

No

If yes, how many per week?

Do you smoke cigarettes?

Yes

No

If yes, how many per day?

If you have tried to lose weight in the past, please describe your approach and methods?

What obstacles do your foresee in reaching your ideal well-being goals (body image, health, wealth)?

If you are human, leave this field blank.

MEDICAL GYNAE

Abnormal Uterine Bleeding
Colposcopy Procedure
Emsella Chair
Endometriosis
Fibroids
Hysterectomy
Incontinence Treatment
Laparoscopy
Menopause Treatment
Menstrual Disorders
Ovarian Cysts
Painful Penetration
Pap Smear Abnormalities
Pelvic Organ Prolapse
Pelvic Pain
Tubal Ligation Surgery

AESTHETIC GYNAE

Labiaplasty
Vaginoplasty
Vaginal Rejuvenation
Labia Fillers
The “Orgasm” Shot
Genital Skin Lightening
Clitoral Hood Reduction
Body Contouring Treatment Fees – June 2020
Aesthetic Procedure Fees – June 2020
Aesthetic Procedure Fees

BODY AESTHETICS

Mommy Make Over
Emsculpt for Muscle Toning & Fat Burning
Exilis – Slimming & Skin Tightening
BTL X-Wave for Cellulite
Vanquish for Fat Reduction
Lymph Drainage
Body Contouring Patient Form

PATIENT INFORMATION

Your First Visit to the Gynaecologist
Having Surgery
Travelling for Surgery
Procedure Fees

PRACTICE LOCATIONS

JOHANNESBURG PRACTICE

Tel: +27 76 242 0027
Intercare Day Hospital Sandton
200 Rivonia Road
Morningside
Sandton

CAPE TOWN PRACTICE

Tel: +27 21 465 6567
SCIN Clinic
Wembley Square North, Solan Street,
Gardens
Cape Town, 8001
South Africa

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