Curva Connect - Exclusive Care, Every Step of the Way

Basic Patient Information

Name *
Nickname
Nationality *
Date of Birth *
Height / Weight
Country of Residence
Preferred Language
Gender *
Preferred Pronouns
Mobile *
Email *

Surgery Information

Medical History

1. Prior hospitalization, long-term outpatient treatment or surgery (if yes, please describe)
2. Are you currently under care for any condition? (if yes, please describe)
3. All Current Medications (prescription and over-the-counter, dosage)
4. Drug Allergies
5. Other Allergies
6. Are you or could you be pregnant?
7. Do you smoke, use tobacco or nicotine porducts? (If yes, how much/how often?)
8. Other physical or mental health conditions that the doctors need to be aware of?

Photos Upload

Please provide photos of the particular area (e.g., hips, nose, eyes, chin) you're considering surgery on, and include close-up photos of that specific region. Providing accurate and comprehensive information will help the surgeon better understand your needs and provide a more accurate quotation.

Upload1

Upload2

Upload3

Upload4

Upload5

Agreement

I authorize the use of my provided information, including photographs and medical history, exclusively for the purpose of obtaining quotations. I understand that this information will be shared solely with the designated surgeons and will not be disclosed to third parties. This agreement is valid only for the duration of the quotation process.

Agree

We are going through security procedures to prevent automatic registration.

as you see Please enter numbers and letters.

Refresh image

Curva Connect Co. Ltd.