As far as possible, we prefer to make all arrangements with you personally by phone. 

Appointments can be made also online, however, so we appreciate you providing us with the following information in order to better serve you.  

 

My first and last name

City - Country

 

 

 Appointments

 

I would like to book a separate appointment for a consultation.

The separate consultation is charged separately. 

See the  price for separate consultation

If you book an operation, the consultation will be deducted from the price of surgery.

  

  I would prefer to book a combined term for consultation and operation.

In the case of a combined appointment the consultation will be scheduled in the morning of the same day of surgery or another day before the operation. You may book an appointment for a consultation and surgery with the deposit of 200 Euros. Before the booking we will inform you about the terms available in the period you prefer and which you may indicate us here below. Also, in the case of a combined booking, our doctors require a photographic documentation to be sent in, for a preliminary evaluation.

 

  

My operation

I intend to have the following aesthetic plastic operation:   

 Other (if not listed) 

  

  

Combined  operation

 

As far as possible, I would like to realize the following combined plastic operation within the same session:   

 

 Other (if not listed) 

 Skin treatments

 

Generally our doctors advice is to perform most surgeries separately in order to keep the risk low and to assure a smooth and problem-free healing period. However, there are certain operations that can be combined under certain conditions. On request our specialist will evaluate your case for a possible combined surgery. A definite decision will be made during the personal consultation.

   

The diagnostics

As far as my operation is performed under general anesthesia, I will arrange the preliminary diagnostics 

 

 

before the journey by the family doctor.

I prefer the diagnostics to be carried out after my arrival at the clinic.

 

My personal data

Age  

Weight  

Height  

 

Preferred dates

My preferred appointments:

Please consider: The waiting time for a consultation is 1-2 weeks. The waiting time for an operation is 5-6 weeks.

My preferred period for the appointment is between  and

  

Arrival & Accomodation

I plan to travel by: 

 

Air [see our suggestions for airlines  ] Rail    Car    still don't know

-------

      I will travel alone      with a companion   still don't know

-------

Yes, pick me/us up when I/we arrive in Prague.

-------

Yes, the hotel-accommodation of my travel companion/s may be arranged.

 

My message

 

Contact

This is my first contact with the Aesthetia team.

I have already been in contact with the Aesthetia team 

My contact person in the team is: ..............................

Tell us how we can contact you:
*E-mail  

E-mail Confirmation

*Cell phone or fix landline phone
Prefix 0044/UK
001/USA-Canada
0061/Australia
other prefix:
Fax

 

(*) important contact data

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