Cosmetic Surgery Questionnaire

*First Name:

*Last Name:

*Gender:

*Address:

*Contact No:

Secondary Contact:

*Email Address:

Desired Hospital Name & City:

Doctor/Surgeon Preference:

*Do you have a passport?

Yes No

Passport Number:

*Date of Birth:

Profession:

*Weight:

*Height:

*Desired Surgery Date:

*The procedure you are requesting or your areas of concern:

For liposuction please state specific area for procedure?

For breast surgery please state your bra size

Choice of breast implants

Saline Silicone

What results do you expect after surgery?

Do you have any of the following medical conditions, please specify yes or no:

*Any breathing difficulties?

Yes No

If yes, please specify:

*Any history of cancer?

Yes No

*Recent trauma (within 1 year)

Yes No

*Any problems with anesthesia?

SURGICAL HISTORY/ Please mention year and procedure

Do you take any hormones?

Are you pregnant?

Yes No

Are you currently lactating?

Yes No

Any medical conditions not mentioned above:

*Do you have any implants or metal objects in your body?

*Do you smoke tobacco?

Yes No

When was your last cigarette or tobacco product?

*Do you drink alcohol?

Yes No

Other Drug Use:

List all medications you currently take including dosage:

Allergies:

*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?

*Ever taken an anticoagulent?

Yes No

If yes, please specify

Leave this empty:

*Attach a File: (max file size: 25MB)

This form is secure and all information and uploads will be submitted over a secure connection.
This form can upload multiple files. Simply select the file from your computer and it will be added to a list below.

Med Tourism Co LLC (www.MedicalTourismCo.com) connects patients to one of the best hospitals in the world. Med Tourism Co LLC does not provide advice on medical treatments nor makes claims or guarantees on the outcome of any medical treatment or surgery. Before making any medical related decision you must thoroughly discuss & seek advice from a qualified medical professional.

I have read the above statement, Terms & Conditions & Health Privacy & Confidentiality Statement on the Medical Tourism Corporation Website.

PERSONAL DETAILS

Do you have any of the following medical conditions, please specify yes or no:

For Women

Medical History