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Send a quote request form


Home Send a quote request form

We would like to thank you for having visited cosmetica Travel website. In order to allow us to answer your queries clearly and thoroughly and in the least possible time, we would like to advise you to fill in all the boxes of the present form and send us two photographs (front and side profile) of the parts of the body that need to be treated. These photographs are absolutely necessary to allow the surgeon to do the preliminary medical diagnosis as accurate as possible.

To preserve your anonymity, and in case of face surgery, you can cover your eyes. These photographs ought to reach us by mail or preferably by email.

NB: Only genuine application forms with photograph attached are to be considered by our surgeon.
All information submitted remains strictly confidential



Step1: Personal details












Make sure you have entered a valid email address before clicking Submit


Procedure






Motivations



Yes    No




* Fields required


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Step2: History details




Yes    No


Yes    No


Medical history

Yes    No


Yes    No


Yes    No


Surgical record

Yes    No


Gynecological and obstetrical record


Yes    No


* Fields required


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Step3: Travel and stay








I have read and accept the terms and conditions of sale *

* Fields required


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Step4: Photos

Important: Only genuine application forms with photograph attached are to be considered by our surgeon.
These photographs are absolutely necessary to allow the surgeon to do the preliminary medical diagnosis as accurate as possible.


Now through this request form
Later on
By e-mail at this address english.contact@cosmeticatravel.com

* Note:
* The size of the files should not exceed 3Mo
* The duration of the remote loading depends on the size of your photographs and your mode of connection to Internet.
* It's preferable to send photographs with JPEG format


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