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English
العربية
فارسی
ورود
register
People who have been consulted and have decided to do surgery should fill out the form below and take photo of the front , right and left profiles of the area they plan to have cosmetic surgery with mobile and place them on the photo upload area
Surgery appointment form
First and last name
(Required)
First
Last
Age
(Required)
Gender
(Required)
Man
Woman
Intended date for surgery
(Required)
DD slash MM slash YYYY
WhatsApp mobile number
(Required)
Information will be sent to you via WhatsApp.
Type of surgery requested
(Required)
Eyebrow and temple lift
Complete face and neck lift
Nose surgery
Ear cosmetic surgery
Facial prosthesis
Chin cosmetic surgery
Tummy lift surgery (abdominoplasty and liposuction)
Torsorrhaphy (abdominal, flank and back lift)
Lipomatic alone
Breast prosthesis
Mammoplasty (breast lift and reduction)
Breast lift and prosthesis
Brachioplasty (arm lift)
Thigh lift
Surgeon's fee in dollars
(Required)
Mentioned in your consultation (surgeon fee only, no hospital fee)
History of specific illness
Heart disease
Glandular disease (such as diabetes or thyroid)
Name of specific medications used
etc
If you have any other specific illness, write here.
Description
If you have any specific explanation, please mention it here
Where to upload photos
(Required)
Front, right, left, and back photos of the area you plan to have cosmetic surgery on, along with a photo of the deposit slip.
Drop files here or
Select files
Max. file size: 128 MB.
Iran (+98)
سلام
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