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Patient Registration & Consultation Booking

Please complete all required fields accurately. Your information is kept strictly confidential.

1. Personal Information
2. Next of Kin
Next of Kin 1
Next of Kin 2
3. Emergency Contact & Referral
Emergency Contact
Family Doctor (Optional)
4. Consultation Details
0/500
5. Vital Statistics
6. Appearance Anxiety Inventory (AAI)

Please answer how often each of the following applies to you. 0 = Not at all   1 = Rarely   2 = Sometimes   3 = Often   4 = All the time

1. I check my appearance (e.g. in mirrors, by touching with my fingers or by taking photos of myself). *
2. I compare aspects of my appearance to others. *
3. I avoid situations or people because of my appearance. *
4. I think about how to camouflage or alter my appearance. *
5. I avoid reflective surfaces, photos, or videos of myself. *
6. I try to camouflage or alter aspects of my appearance. *
7. I brood about past events or reasons to explain why I look the way I do. *
8. I am focused on how I feel I look rather than on my surroundings. *
9. I discuss my appearance with others or question them about it. *
10. I try to prevent people from seeing aspects of my appearance within particular situations (e.g. by changing my posture, avoiding bright lights). *
7. Medical History

Check the appropriate answer. If you do not know the correct answer, please write "Don't know" in the details field.

Are you currently under a physician's care? *
Are you taking any medications, substances and/or vitamins? *
Are you allergic to any medications and/or foods? *
Do you have a family history of unexplained death following general anaesthesia or exercise? *
Are you allergic to any metals or latex? *
Are you pregnant or do you suspect you may be? *
Do you use any birth control medications? *
Have you ever been treated for or told you might have heart disease or a heart condition? *
Do you have high or low blood pressure? *
Do you have a pacemaker or an artificial heart valve implant? *
Have you ever had a rheumatic fever? *
Have you used isotretinoin or any pill for acne management? *
Have you ever taken PHENTERMINE or any weight loss pill? *
Have you ever had a serious illness or previous surgery? *
Have you ever had plastic surgery? *
Have you ever had radiation or chemotherapy treatment for a tumour or other condition? *
Do you have any blood disorder such as anaemia, leukaemia and/or immunodeficiency disorders? *
Have you ever bled excessively after being cut or injured? *
Do you have acid reflux, hiatal hernia, ulcers or difficulty swallowing? *
Do you have any kidney or liver problems? *
Are you diabetic? *
Do you have asthma? *
Do you have epilepsy or seizure disorders? *
Do you have a history of sleep apnea? *
Are you HIV positive? *
Have you had or do you test positive for Hepatitis? *
Do you have or have you had Tuberculosis (T.B.)? *
Do you smoke, chew, use snuff or any other forms of tobacco including cigars? *
Do you consume alcoholic beverages? *
Do you habitually use marijuana, cocaine or other illegal substances? *
Have you ever had psychiatric treatment? *
Would you accept a blood transfusion in an emergency? *
Do you have any disease, condition or problem not listed above? *
Do you have a personal or family history of? (Tick all that apply) *

PATIENT MEDICAL HISTORY CERTIFICATION

I certify that the above information is complete and accurate.

8. Skin Necrosis Prevention Questionnaire

0 = Not at all  |  5 = All the time

Do you smoke? *
Do you stay around people that smoke? *
Do you use nicotine products? (gum, vape, shisha, etc.) *
Do you use skin lightening products? *
Does your skin bruise easily? *
Do you take any substance not mentioned above? *
9. Consent & Declaration

IMPORTANT — FEES & CANCELLATION POLICY

All fees paid for any procedure are non-refundable. If a client cancels his/her surgery before the day of surgery, he/she will forfeit 30% of the total amount paid for administrative charges, or 50% if cancellation occurs on surgery day. Date rescheduling one week or more before surgery attracts a surcharge of ₦100,000; rescheduling on surgery day attracts a surcharge of ₦200,000. If for any reason the client cancels a recovery home stay after payment has been made, he/she will forfeit 30% of the total amount paid for administrative charges.

PHYSICIAN'S RELEASE AND ASSIGNMENT

I understand that I am financially responsible for all charges incurred by me, and I agree that in the event that this account is referred to collections, to pay all collection expenses incurred as a result of the surgery, both post and pre-op.

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Your information is kept strictly confidential and will only be used to provide your consultation and medical care.