Annex No. 1 to the agreement on the price and conditions of plastic surgery

Health information (anamnesis)
Plastic surgery

Select clinic

Client‘s personal data

Are you being treated for or have you suffered (please, specify):

High blood pressure (hypertension)?

Heart attack or ischemic heart disease?

Heart disease, heart rhythm disorder?

Stroke?

Lung diseases (asthma, emphysema, inflammations)?

Chronic inflammation of liver (hepatitis A, B, C)?

Chronic inflammation or another kidney disease?

Gastric, duodenal or esophageal ulcers?

Hernia in the area of the navel or abdominal wall?

Diabetes?

Decreased or increased thyroid function?

Tendency to bleeding or bruising?

Inflammation or venous obstruction in lower extremities?

Chronic joint inflammation, problems with the spine?

Recurrent or chronic infections?

Epilepsy (convulsion-fits)?

Migraine?

Mental disorder?

An allergic reaction to drugs? Indicate which ones.

Other allergies (pollen, feathers, food etc.)? Indicate which ones.

A serious head injury with unconsciousness? State which one.

Surgical procedures (including plastic surgeries)? Indicate when, which and at which workplace (at which doctor):

Malignant hyperthermia (severe, life-threatening reaction to general aesthesia with very high temperatures and muscle spasm)? Mention the occurrence not only in you, but also in the family.

Other diseases of a serious nature (e. g. AIDS or other infectious diseases)? Indicate which ones.

Other health problems or restrictions? Indicate which ones (current health status, e. g. cold, runny nose, cough, etc.):

Are you taking any medications for a long time? Indicate which ones (incl. contraception).

Are you currently taking any medications? Please specify which ones. (including birth control and weight loss medications such as Ozempic, Mounjaro, Trulicity, Wegovy, etc.)

Do you have fixed or removable dental prostheses? Loose teeth? Crowns or implants? Damaged teeth? If yes, describe:

Has your weight changed significantly in the last six months? How?

Do you drink alcohol? How often? How much?

Do you drink coffee? How many cups a day?

Do you use drugs? Indicate which ones.

Do you smoke? If yes, indicate the approximate number of cigarettes.

What‘s your job? Type of work (sedentary, physical, mental, light, heavy, etc.)?

Fill in if you are going for a consultation on breast surgery:

Number of children and years of their birth:

Breast diseases, if so, which one:

Has breast cancer occurred in the family, if so, in whom:

Please, specify bra size:

Information for women only: Plastic surgery cannot be performed while the client is pregnant!

In case of doubt, it is necessary to perform a pregnancy test, or to visit a gynaecologist! By signing this document, the client declares that she is not pregnant for the purposes of performing the intervention. Blood clotting may be adversely affected during and just before menstruation, so it is recommended to plan the procedure for another period

I declare that I have fully understood and answered all the above questions truthfully and completely. I had the opportunity to ask any question; all the questions I asked were answered. I understand the need to have a preoperative examination (blood tests, ECG and possibly others, as required by MEDICOM CLINIC doctor) and I acknowledge that without their presentation it will not be possible to perform the required intervention.

By signing this document, the client agrees that the MEDICOM CLINIC a. s., health care establishment with registered office in Prague 1 - Nové Město, Spálená 75/16, postal code 110 00, company ID: 247 56 148, registered under file no. No. B 16606 at the Municipal Court in Prague (hereinafter also referred to as the “data controller”), as the data controller pursuant to Act No. 110/2019 Coll., on the processing of personal data, as amended (hereinafter referred to as the “Personal Data Processing Act”), collects, stores and processes his/her personal data (including the sensitive ones), namely the following data: name, surname, personal identification number, address of permanent residence, telephone contact, e-mail contact, data kept in accordance with applicable laws in the client‘s medical records, health insurance company, exclusively for the purpose of subsequent intervention, resp. to keep medical records on it, whereas MEDICOM CLINIC a. s. will be the service provider and the data subject will be their recipient. The client declares that he/she has been informed of his/her rights pursuant to § 28 and § 29 of the Personal Data Processing Act. This means in particular that the provision of personal data to the data controller for this purpose is voluntary, that the data subject (client) has the right to access them, has the right to revoke the above consent at any time in writing at the controller‘s address (provided that the client acknowledges that in relation to each controller the consent must be revoked separately), and also has the right to contact the Office for Personal Data Protection in the event of a breach of its rights and to request appropriate redress. This redress can be, for example, refraining from such actions of the controller, removing the situation, providing an apology, making corrections or additions, blocking, liquidation of personal data, payment of monetary compensation, as well as the use of other rights arising from § 29 and § 32 of the Personal Data Protection Act. Data controller declares that it will collect personal data to the extent necessary to fulfil the specified purpose and process them only in accordance with the purpose for which they were collected. Employees of the data controller or other natural persons who process personal data on the basis of a contract with the data controller and other persons who will have access to personal data on the basis of this consent are obliged to maintain the confidentiality of personal data, even after their termination of employment or work. Personal data is fully secured against misuse.