Free Urological Evaluation
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*Full Name
(as it appears in your passport):
 
*Nationality:  

Passport or Travel Document Number:  
*Date of Birth:  
Current Address:  
ZIP  
City  
State  
Phone Numbers:  
Cellulare  
* Email Address:  
Weight:  
Height:  
Name of Persons to Contact in Case of Emergency:  
Contact Person's Email Address:  
Contact Person's Phone Number:  
Contact Person's Address:  
Planned Date of Surgery:  
There is no “waiting list”. Request the surgery date you want and we will confirm it or propose the closest available date.
Date You Expect to Fly Home:  
What Procedure(s) Do You Require?  
What Specific Results Do You Expect?  
Questions:  
What is your flaccid penis length?  
What is your flaccid penis circumference?  
Are you able to have an erection?   Yes - No
How long are you able to maintain an erection?  
What is your erect penis length?  
What is your erect penis circumference?  
*Send us a sharply-focused, clear, well-lit, unedited photos of your penis in flaccid & erect states from left, right & center  

Send as zipped (one archive) attachments digital photos of your penis from left, right, center, above and below in flaccid and erect states. No need to crop, re-size or do anything to the photos. Send them to us exactly as they come out of the camera and we will prepare them for Dr Perovic's optimum viewing. They must be in focus. Do not get the camera too close. It does not make better photos. Flash photos in a room with good ambient daylight from about 100-150 cm (3.5-5 feet) away tend to come out best.
Diabetes or Blood Sugar Problems?   Yes - No
Thyroid Problems?   Yes - No
Heart Problems?    Yes - No
If yes, please explain:  
Lung Problems (such asthma or other other breathing difficulties)?   Yes - No
If yes, please explain:  
Blood Pressure Problems?   Yes - No
Previous or Current History of Cancer?   Yes - No
If yes, please explain in detail:  
Kidney or Liver Problems?   Yes - No
Have you had any traumatic experience during the past year such as a divorce, loss of a loved one or extreme stress?   Yes - No
Problems with Anesthesia?   Yes - No
Blood Disorders (such as bleeding or clotting problems)?   Yes - No
Are you HIV+ or do you have AIDS?   Yes - No
All patients must have HIV, Hepatitis B & Hepatitis C tests. Send the results to us as an email attachment or bring results when you come. Tests can be done in Belgrade but are not included in price & cost Euros €50. HIV+ or Hepatitis C positive results disqualify a person from elective surgeries.
Have you been hospitalized, had surgery or received medical care within the past 12 months?   Yes - No
If yes, when?  
If yes, for what reason?  
Have you had weight loss surgery?   Yes - No
If yes, when?  
If yes, which procedure did you have?  
If yes, how much weight have you lost since your surgery?  
Do you have any implants or any metal objects in your body?   Yes - No
If yes, please specify:  
Do you form keloids or have any difficulty with healing or scarring?   Yes - No
Any Nervous Breakdowns or Depression?   Yes - No
Neurologic Problems?   Yes - No
Have you previously had any type of surgery?   Yes - No
If yes, list procedure(s) and date performed:  
List all medications you currently take, including dosage:  
List all vitamins or other nutritional supplements you take:  
Any Allergies?   Yes - No
Food Allergies?    Yes - No
Drug Allergies?    Yes - No
If you have any allergies, please specify:  
Have you ever taken an MAO inhibitor such as Nardil®, Marplan® or Parnate®?   Yes - No
If yes, when was your last dose?  
Have you ever taken an anticoagulant such as Coumadin®, Heparin ® or a daily aspirin?   Yes - No
If yes, when was your last dose?  
Have you ever smoked tobacco?   Yes - No
How much do you smoke now?  
When was your last cigarette or tobacco product?  
Do you drink alcohol?   Yes - No
If yes, what type, how much and how often?  
Have you had or do you have any medical conditions not mentioned above?   Yes - No
If yes, please explain:  
Additional info we should know but we didn't ask about:  
Are you taking any form of anti-depressants?    Yes - No
Have you made yourself aware of the risks involved in the the medical treatment you want?    Yes - No
Have you read the article: “Complications of Surgery”?   Yes - No
    * Required field
   






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