Free Consultation

Your Full Name *

Email *

Phone *

Nationality *

Date of Birth *

Age *

Gender *

Female Male

Height (cm) *

Weight (kg) *

Address *

Preferred Date Of Surgery? *

Leave Thailand On (Date)? *

Passport Number

Your Preferred Procedures? *

Your Preferred Surgeon?/ What Results Do You Expect? / Any Question to the surgeon? *

Please select if the following medical conditions apply to you. *(You can select multiple)

Diabetes or Blood Sugar Problems Blood Pressure Problems Blood Disorders Thryriod Problems Lung Problems Kidney or Liver Problems Previous or Current History Of Cancer Nervous Breakdown or Depression Neurologic Problems HIV or AIDS Anesthesia Problems I DON'T HAVE ANY MEDICAL CONDITIONS MENTIONED ABOVE

Please describe if you HAVE SELECTED one or more medical conditions shown above/ or if you have OTHER MEDICAL PROBLEMS not mentioned above(Explain about your treatment, eg. name of medications and usage /per day )

Please select the following activities that apply to you. *(You can select multiple)

I have been hospitalised, had surgery or received medical care within the past 12 months. I had surgery before. I have implants or metal objects in my body. I have difficulty with healing or scarring. I have allergie to food or drugs or etc. I have ever taken a MAO Inhibitor such as Nardil, Marplant or Parmate. I have ever taken an anticoagulant such ah Coumadin, Heparin or a daily Aspirin. I smoke I drink alcohol NONE OF ABOVE MATCHED MYSELF

If you HAVE SELECTED one or more activities above, please give details

FEMALE SECTION: Please select the following choices apply to you *(You can select multiple)

I take birth control pills, hormone replacement medication, or wear a hormone patch. I have undergone surgical means of birth control (e.g. Tubal Ligation). I am now pregnant. I am planning more pregnancies. I have child or children. I have ever breastfed. My breasts still have milk at this time NONE OF ABOVE MATCHED MYSELF

If you have children of ever breastfed, please give details.(How old is your youngest child?/ When is your last breastfeed?)

I hereby confirm that I have provided correct and complete information about my medical history. *

Your Consent

Free Consultation Request Form

Please attach photo of your concerned part ( Taken cleary from 3 views; FRONT LEFT RIGHT )

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