Client Questionnaire

What happens
after you submit

Dr. Zuzana Cerna
Chief Surgeon

Your information will only be viewed by Laderma chief surgeon Dr. Cerna and patient coordinator Katka Formankova.

Katka Formankova
Patient Coordinator

We will let you know in two business days about our opinion on your procedure and about open operation date.

This questionnaire has been designed to make the initial communication between our clients
and the Clinic easier and more accurate.

Please fill out all information marked with *.

Thank you very much for your co-operation.

First Name*:
Last Name*:
Sex:	male female
Date of Birth:
Intended Procedure:
Country of Residence:
Mobil phone:
	*please enter phone and e-mail, we will contact you on the phone only in case of emergency
E-mail:
Preferable Date of Operation:
How did you find out about us?:

	Please attach a photo of the part of your body you intend to have an operation on, or write a link for us to view it.

Photo 1:
Photo 2:
Photo 3:

Additional information:

	The form is beeing sent to Laderma Please note. Since you attached picture(s), the form may take quite a long time to submit. In some cases, if the pictures are really big, the form doesn't get thru at all. That's why if you don't hear from us in two days, please contact us via e-mail at info@laderma.com.