Cosmetic Surgery ThailandThailand Plastic Surgery
Plastic Surgery Thailand

Plastic Surgery Thailand

Clients are requested to complete this form as fully as possible as the more information you provide will allow us to make a more informed decision regarding your eligibility to complete a plastic surgery procedure. Please also refer to the section on photographs.

To download this form please click here PDF File Word File

PATIENT DETAILS
Title Name :
    *
First Name :
    *
Middle Name :
  
Family/Last Name :
    *
Gender :
    Male   Female    *
Date of birth :
    /  /  *
Height :
    
Weight :
    
Blood Group :
    
Marital Status :
  
Nationality :
    *

CONTACT INFORMATION
Home address :
    *
Address :
    *
Street :
  
City/Town :
    *
Country :
     *
Zip/Post Code :
    
Email :
    *
Tel(Home) :
  
Tel(Office) :
  
Mobile :
    *
How long have you been living at your home address :
  

TRAVEL COMPANIONS DETAILS
Title Name :
  
First Name :
  
Middle Name :
  
Family/Last Name :
  

BOOKING DETAILS
Procedure/s Requested :
  
Requested Date of Surgery :
    /  /
Depart Phuket on (Date) :
    /  /

FAMILY MEDICAL CONDITION
Heart Disease :
   Not Known None Yes (Please specify)
Diabetes :
   Not Known None Yes (Please specify)
Hypertension :
   Not Known None Yes (Please specify)
Asthma :
   Not Known None Yes (Please specify)
Cancer :
   Not Known None Yes (Please specify)

PATIENTS MEDICAL CONDITION
Heart Disease :
   Not Known None Yes (Please specify)
Diabetes :
   Not Known None Yes (Please specify)
Hypertension :
   Not Known None Yes (Please specify)
Deep Vein Thrombosis :
   Not Known None Yes (Please specify)
Cardiovascular Accidents :
   Not Known None Yes (Please specify)
Asthma :
   Not Known None Yes (Please specify)
Bleeding Tendency :
   Not Known None Yes (Please specify)
Hyperthyroidism :
   Not Known None Yes (Please specify)
Hypothyroidism :
   Not Known None Yes (Please specify)
Adrenal Insufficiency :
   Not Known None Yes (Please specify)
Hepatitis :
   Not Known None Yes (Please specify)
HIV :
   Not Known None Yes (Please specify)
Keloid Scarring :
   Not Known None Yes (Please specify)
Cancer :
   Not Known None Yes (Please specify)
Major Operation :
   Not Known None Yes (Please specify)
Other :
   Not Known None Yes (Please specify)
Underlying Disease :
   Not Known None Yes (Please specify)
Drug Allergies :
   Not Known None Yes (Please specify)
Food Allergies :
   Not Known None Yes (Please specify)
Current Medications and Dosage :
   Not Known None Yes (Please specify)
Current vitamins,food/nutritional supplements :
   Not Known None Yes (Please specify)
Have you ever been treated for depression :
   Not Known None Yes (Please specify)


HABITS HISTORY
Smoking :
   Not Known None Yes (Please specify)
Drinking :
   Not Known None Yes (Please specify)

FOR WOMEN ONLY
Birth control pills , hormone replacement medications , hormone patch / implant :
   Not Known None Yes (Please specify)
Are you pregnant now :
   Not Known None Yes (Please specify)
Planning for more pregnancies?:
   Not Known None Yes (Please specify)
Age of youngest child :
  
last breastfed on (month & year) :
    /

BREAST SURGERY DETAILS
Current Bra Size :
  
Requested Size :
  
Desired Placement :
  
Desired Implant :
  
Desired Incision :
  

Type the code shown :      *