Plastic & Aesthetic Surgery
Patient Anamnesis

Plastic Surgery Medical Form

Please complete each section. Your information is encrypted and shared only with Dr. Cömert's clinical team.

Personal & Contact

Standard identifying information.

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Female Male Prefer not to say
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Select nationality▾
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Enter a valid email
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Enter your phone number

Address & Emergency Contact

Where you live and who we should contact if needed.

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Emergency contact
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Height & Weight

Your BMI is calculated automatically — it's one factor reviewed for surgical readiness.

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Required
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Enter your height and weight
27 — our limit
15202530
Why this matters: for procedures such as the deep plane facelift and facial implants, a BMI above 27 can affect anaesthesia safety, healing and the final result. This tool is for guidance only — suitability is always assessed individually at consultation.

Medical History & Medications

Check everything that applies. Accuracy here is essential for your safety.

✓None of these ✓Hypertension (high blood pressure) ✓Diabetes (Type 1 or 2) ✓Heart disease / cardiac arrhythmia ✓Thyroid disorders ✓Blood clotting disorder / DVT ✓Autoimmune disease (Lupus, RA, etc.) ✓HIV / Hepatitis B / C ✓Keloid / abnormal scarring tendency ✓Psychiatric / psychological treatment
Select at least one (choose "None" if not applicable)
Required — please describe the condition(s) you selected
Hormones, blood thinners & related medications
✓None of these ✓Hormone Replacement Therapy (HRT) ✓Oestrogen / Progesterone ✓Testosterone ✓Contraceptive pill / hormonal IUD / implant ✓Blood thinners (Warfarin, Heparin, Xarelto, Eliquis) ✓Antiplatelets (Aspirin, Plavix / Clopidogrel) ✓NSAIDs regularly (Ibuprofen, Naproxen) ✓Corticosteroids / steroids (Prednisone) ✓Antidepressants / psychiatric medication ✓Weight-loss medication (GLP-1 — Ozempic, Wegovy, Mounjaro, Saxenda) ✓Herbal supplements / vitamins (Fish Oil, Vit E, Garlic, Ginkgo)
Select at least one (choose "None" if not applicable)
Required — write "None" if not applicable

Surgical History & Lifestyle

Please answer each question.

Previous surgeries & anaesthesia
Have you had any previous surgeries?
Required
Have you ever had complications with anaesthesia?
Required
Have you ever had a blood transfusion?
Required
Are you currently pregnant or breastfeeding?
Required
Lifestyle, smoking, alcohol & allergies
Do you smoke? (cigarettes, vaping, etc.)
Required
Do you consume alcohol regularly?
Required
Do you use any recreational drugs?
Required
Do you have any known allergies (medication, latex, food, other)?
Required

Procedure & Goals

Tell us what you are interested in and what you hope to achieve.

✓Deep Plane Facelift ✓Neck Lift ✓Brow Lift ✓Temporal Lift ✓Rhinoplasty ✓Eyelid (Blepharoplasty) ✓Facial Implants ✓Orthognathic / Double Jaw ✓Facial Feminization ✓Facial Masculinization ✓Fat Grafting ✓Breast (Augmentation / Lift / Reduction) ✓Filler ✓Botox ✓Mesotherapy ✓Other / Not sure yet
Select at least one
Please share your goals

Photos & Documents

Upload clear photos following the guide below. You can also add a CT scan and any medical reports if you have them.

📱
Guided capture with your phoneRecommended

A live guide shows each pose on your phone — the frame turns green when your angle matches the example, and your photos appear here automatically.

📷Tap to add photosJPG / PNG / HEIC · up to 15 MB each
Please upload at least 5 photos
CT scan — optional

If you have a CT scan (jaw, implant or rhinoplasty planning), upload it here — DICOM, ZIP, PDF or image files.

🧠Tap to add CT scanDICOM / ZIP / PDF / images · up to 90 MB each
Medical reports & documents — optional

Blood tests, anaesthesia reports, previous operation notes or any other documents.

📄Tap to add documentsPDF / images / DOC · up to 90 MB each

Consents & Declaration

Please review and accept each item to submit your form.

✓

KVKK — Processing of Personal Data (Türkiye)

I consent to the processing of my personal and health data under Law No. 6698 (KVKK) for medical consultation and treatment coordination.

Under the Personal Data Protection Law No. 6698 (KVKK), Dr. Mehmet Cömert's clinic, as data controller, processes the special-category health data and contact details you provide solely to assess your suitability for treatment, plan your care and contact you. Your data is stored securely, not shared with third parties without your consent except where legally required, and retained only as long as necessary. You may request access, correction or deletion of your data at any time via [email protected].
✓

GDPR — Data Protection (EU/EEA)

I give explicit consent for my personal and health data to be processed under the EU GDPR for the purposes described.

Under the EU General Data Protection Regulation (GDPR), you provide explicit consent (Art. 9(2)(a)) for processing special-category health data for medical assessment and treatment coordination. The lawful basis is your consent and the provision of healthcare. You have the right to access, rectify, erase, restrict and port your data, and to withdraw consent at any time, without affecting prior lawful processing.
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Cookie Policy

I accept the use of essential, first-party cookies required for this form to function.

This form uses only essential, first-party cookies and local storage needed to keep your progress and submit securely. No advertising or third-party tracking cookies are set within this form. You can clear them at any time in your browser settings.
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Declaration & Treatment Consent

I declare the information provided is accurate and complete, and consent to its use by Dr. Cömert's team to plan and perform my procedure.

I hereby declare that all the information provided in this form is accurate and complete to the best of my knowledge. I understand that any misrepresentation or omission of information may affect my treatment plan and could result in complications. I consent to the use of this information by Op. Dr. Mehmet Cömert and his medical team for the purpose of planning and performing my surgical procedure. This form is not a diagnosis and does not guarantee that any procedure will be offered; final suitability is determined only after a personal medical evaluation.

Procedure-specific consent forms

Please review the surgical consent form(s) relevant to your selected procedure(s). These will also be signed in person before surgery.

✓

Thank you

Your medical form has been received. Dr. Cömert's team will review it and contact you shortly. A confirmation has been sent to your email.

🔒 Encrypted & KVKK / GDPR compliant · Op. Dr. Mehmet Cömert · drmehmetcomert.com