Date

Surname*

First name*

Date of birth*

e-mail address*

Telephone number*

Street

House number

Place of residence

ZIP CODE

LipedemaInitial consultationFollow-up meetingOP preliminary discussionOP debriefing

Lipedema stageStage 1Stage 2Stage 3

AestheticsInitial consultationFollow-up meeting

Treatment- Please select -Aesthetic medicine:Botox® treatmentAutologous blood treatmentThread liftingFotana laser treatmentHyaluron treatmentLypolysis - fat removal injectionMicro-needlingMorpheus8 treatmentPolynucleotide treatmentPRP for hair lossProfhilo treatmentAesthetic surgery:Eyelid liftAesthetic liposuction - liposuctionAbdominoplastyBreast correctionBreast liftBreast augmentation with autologous fatBreast augmentation with implantsBreast reductionAutologous fat transplantation faceGynecomastiaIntimate surgeryCombination interventionEyelid liftMommy makeoverUpper arm liftThigh lift

Have you ever been advised by another doctor?YesNo

Have you already had surgery?YesNo

With which doctor? Name of the practice.

Which operation?

How did you hear about us or who recommended us?
Doctor recommendationPersonal recommendationSearch engine (e.g. Google)Online advertising (e.g. Google)Social media (Instagram / Facebook / YouTube etc.)Print media / TVMiscellaneous

Recommending doctor / Other information on the recommendation