Surgeons Online Assessment Form
First Name
Last Name
Email
Phone Number
Address
Choose 1 or more
Female
Male
Travel Companion
Yes
No
Companions Full Name
Date of Birth
Passport Number
Preferred Date of Surgery
2nd Preferred Date of Surgery
Emergency Contact Name
Emergency Contact Ph Number
PERSONAL DETAILS
The surgeons will require all the following details for you to receive a personalised summary of advice and an estimate of cost. Please note that a plan of your surgery will be finalised at the personal consultation with the surgeon you choose.
Height
Weight
Family Medical Conditions
Yes
No
Family Medical Conditions (Please Specify)
Have you had surgery in the past? (Please specify)
Medical History? Please specify
Do you have any drug allergies? Please specify
Do you have any underlying disease or medical condition? Please specify
Are you taking any medications? Please specify
Current Vitamins, food nutritional supplements? Please specify
Do you smoke or drink? Please specify frequency per week
Have you or are you being treated for depression? Please specify
Procedure Requested (Please specify the surgery you are interested in)
WOMEN
Please fill in the following information if you are requesting breast surgery.
Are you pregnant now?
Yes
No
Are you planning for more pregnancies
Yes
No
Age of your youngest child
Last Breastfed (Please specify month and year)
Desired Implant
Select an option
Round
Tear Drop
Requested Size
Current bra size
I agree to the terms & conditions
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