Online Consultation Form

Please Complete this form

Full Name

Sex
—FemaleMale

Date of Birth

Marital Status
—SingleMarriedDivorcedWidowedWidower

Country of Origin
Select CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua And BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamas TheBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo The Democratic Republic Of TheCook IslandsCosta RicaCote D'Ivoire (Ivory Coast)Croatia (Hrvatska)CubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFiji IslandsFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambia TheGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernsey and AlderneyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHondurasHong Kong S.A.R.HungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacau S.A.R.MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMan (Isle of)Marshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlands AntillesNetherlands TheNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory OccupiedPanamaPapua new GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts And NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent And The GrenadinesSaint-BarthelemySaint-Martin (French part)SamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth SudanSpainSri LankaSudanSurinameSvalbard And Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad And TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican City State (Holy See)VenezuelaVietnamVirgin Islands (British)Virgin Islands (US)Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabwe

Residential/ Digital Address Address

Email

Mobile No.

Your Height (inches)

Your Weight 1-3months ago (pounds)

Your Weight before (pounds)

Are you taking some medications currently
YesNo

If Yes please List

Do you have any illness that concerns you
YesNo

If Yes please List

Do you have Diabetes,hypertension, heart disease,
kidney,lung,liver disease,sickle cell disease
or any other disease
YesNo

If Yes please List

Have you done any surgeries in the past
YesNo

If Yes please List

Have you done any cosmetic surgeries in the past
YesNo

If Yes please List

Number of Children

Do have any bleeding disorder
YesNo

Do you have any other medical condition you will like
to inform the Medical Doctor
YesNo

If Yes please List

Do you have any medical condition you want to keep very secret
YesNo

Do you Smoke or drink
YesNo

Do you smoke or drink alcohol very heavily
YesNo

If Yes please List Types

Number of Cigarettes smoked in a day

Your specific request(s) regarding the procedure
you wish to undertake

Do you know anyone who has done this procedure
YesNo

Please attach nude photos /videos of yourself taken
from the neck to the knee level for evaluation by
Dr. D.K. Obeng -Andoh. The shots should come under the
following Front, Back, Right and Left side views.

PLEASE DO NOT INCLUDE YOUR FACE.
PLEASE ATTACH EITHER PHOTOS OR VIDEOS.
DO NOT SEND BOTH PHOTOS AND VIDEOS AT THE SAME TIME
Photo(FrontView)
Photo(BackView)
Photo(RightView)
Photo(LeftView)
Video(AllViews)