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Beat The Credit Crunch



Zdenka - Your Client Liaison Manager!





 

Client Liaison Manager:
Suzie Jacobs

Email:
info@new-you.net

natasha@new-you.net

suzie@new-you.net

Our Team

freephone

NEW YOU: Telephone 0800 012 5850 / 0203 199 5656 (UK)
(Business Hours; 9am to 7pm)

Registered Office in UK:
European Weight Loss Centre Ltd
(t/a NEW YOU)
1st Floor
2 Woodberry Grove
London
N12 0DR

Alternatively, we can call YOU at a time to suit, simply click here

We are more than happy to answer any questions you may have to give you COMPLETE peace of mind!

Please take the time to look at our GENUINE testimonials, as they are clearly honest and real TESTIMONIAL VIDEOS: Here

Please carefully complete the medical questionnaire below, answering all questions, in order that we can process your requirements. Thank you. (Completion of this questionnaire will take approx 2 minutes).

We look forward to being of service to you - the NEW YOU is just around the corner !

Full Name
Address
Phone
Mobile
  Note: Mobile numbers may be given to our clinic in case they need to contact you during your stay in Prague
E-Mail
Date of Birth
Sex

Procedure required - please give details of the procedures that you would like to be carried out. It may e possible to have more than one procedure carried out during your stay

Please answer the following questions:

Have you been diagnosed with Hepatitis A,B or C ? Yes No
Are you HIV positive ? Yes No
Do you smoke ? Yes No
How many per day ?
Have you ever had a serious illness, disease or injury ? Yes No
If yes please provide details:
Have you undergone any operations with general anaesthetic ? Yes No
If yes please provide details:
Have you ever received a local anaesthetic ? (for example at the detist, wart removal, etc) Yes No
If yes please provide details:
Are you currently taking any prescribed medication ? Yes No
If yes please provide details:
Are you being treated for any illness or disease ? Yes No
If yes please provide details:
Are you allergic to any drugs ? Yes No
If yes please provide details:

Do you suffer from any of the following conditions ?

High blood pressure ? Yes No
Heart palpitations ? Yes No
Diabetes ? Yes No
Blood clotting problems ? Yes No
Heart disease ? Yes No
Breathing or Lung problems ? Yes No
Over-active thyroid ? Yes No
Under-active thyroid ? Yes No
Breast problems ? Yes No
If yes please give us details to any other conditions you have had:

 

Please answer the following:

Age ? Years 
Height ? In Feet&Inches or Cm's 
Weight ? In Stones / Lbs or Kg's 

Do you lead a healthy life? Yes No
Do you take regular excercise ? Yes No
Are you pregnant or planning to be in next 6 months ? Yes No
Are you taking any hormonal contraception? Yes No
If yes please specify what drug and the reason for taking:


This document is strictly confidential and is for clinical use only. All information is strictly confidential. It is important that you are factual and accurate in your completion of your medial questionnaire, in order that we can serve you quickly, safely and efficently.


ADDITIONAL INFORMATION
(Please also complete this section)

Procedure(s) wished


Which airport you would prefer to fly from ?
Which date would best suit you for surgery ?
  (This date cannot be guaranteed, if unavailable we willl try to get you the closest date possible)

 

I hereby undertake that the information given in this questionnaire is correct and that I have read, understood and agreed to the Terms & Conditions. A copy of our terms and conditions can be found here

 

 

(c) 2007 Copyright - New You. All rights reserved.