Medical Form

Title *

First Name *

Middle Name

Last Name *

Gender *

DOB *

Height (cm) *

Weight (kg) *

Nationality *

Passport No. *

Contact Information

Address 1 *

Address 2

City *

State/Province

Country *

Post Code *

Email *

Phone *

Secondary Phone

Are you contactable on any of the following apps?

Skype

What’s App

Messenger

(Please download one of the above Apps for ease of communication by our office and concierge once you leave your home country)

Emergency Contact Details

First Name *

Last Name *

Phone *

Secondary Phone

Travel Companion Details

Title

First Name

Middle Name

Last Name

Your Surgery Holiday:

Preferred Destination *

Preferred Hotel Room *

Surgery Treatments/Packages 1 *

Surgery Treatments/Packages 2

Surgery Treatments/Packages 3

Surgery Treatments/Packages 4

Preferred Hospital *

Preferred Surgeon *

Dates

Arrival Date *

Departure Date *

Requested Date of Surgery, if known

Flight Details

Arrival Destination Airline

Arrival Destination Flight Number

Departure Destination Airline

Departure Destination Flight Number

Family Medical Conditions Heart Disease

Not Known

None

Yes

Diabetes

Not Known

None

Yes

Hypertension

Not Known

None

Yes

Asthma

Not Known

None

Yes

Cancer

Not Known

None

Yes

Patient Medical Conditions Heart Disease

Not Known

None

Yes

Diabetes

Not Known

None

Yes

Hypertension

Not Known

None

Yes

Deep Vein Thrombosis

Not Known

None

Yes

Cardiovascular Accidents

Not Known

None

Yes

Asthma

Not Known

None

Yes

Bleeding Tendency

Not Known

None

Yes

Hypertheyroidism

Not Known

None

Yes

Adrenal Insufficiency

Not Known

None

Yes

Hepatitis

Not Known

None

Yes

HIV

Not Known

None

Yes

Keloid Scarring

Not Known

None

Yes

Cancer

Not Known

None

Yes

Major Operation

Not Known

None

Yes

Other

Not Known

None

Yes

Underlying Disease

Not Known

None

Yes

Drug Allergies

Not Known

None

Yes

Food Allergies

Not Known

None

Yes

Current Medications and Dosage

Not Known

None

Yes

Current vitamins, food nutritional supplements

Not Known

None

Yes

Have you ever been treated for depression

Not Known

None

Yes

Current blood pressure (if known)

Habits Smoking

Not Known

None

Yes

Drinking

Not Known

None

Yes

Women Birth control pills, hormone replacement medications, hormone patch or implant

Not Known

None

Yes

Are you pregnant now

Not Known

None

Yes

Planning for more pregnancies

Not Known

None

Yes

Age of youngest child

Last breastfed on (month & year)

Breast Surgery Details

Current Bra Size

Requested Size

Desired Placement

Desired Implant

Desired Incision

Expected Outcome

Photos

Photos are submitted directly to the surgeons for evaulation and feedback. Information on how to take photos can be found on our website. All our surgeons are Senior Surgeons and have been selected by us for their excellent skills in plastic surgery. Feedback and evaluation can take up to 5 business days. Once this is received, your consultant will review the options available and answer any of your questions.

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