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What’s app: +66 819892565
Medical Inquiry Form
Medical Inquiry Form
Contact Information
Last Name :
*
First Name :
*
E-mail Address :
*
Phone :
*
Address :
*
Address2 :
*
City :
*
State :
*
Zip/Postal Code :
*
Country :
*
Emergency Contact Information
Last Name :
*
First Name :
*
E-mail Address :
*
Phone :
*
Address :
*
Address2 :
*
City :
*
State :
*
Zip/Postal Code :
*
Country :
*
Requested Procedure (Please provide us with as much detail as possible).
Please tell us which procedure you are interested in receiving:
*
Why are you interested in receiving the above procedure?
*
(Please be as honest as possible when responding to the above question - it is important that the doctor truly understands the purpose).
General Information/Statistics
Gender : ( Please specific )
*
Date of Birth
*
Height : Centimeter
*
Weight : Kilogram
*
Medical Conditions
Are you/have you ever had:
Aids or HIV positive :
*
Yes
No
Anemia :
*
Yes
No
Arthritis :
*
Yes
No
Asthma :
*
Yes
No
Back Problems :
*
Yes
No
Blood Clots :
*
Yes
No
Blood Disorders :
*
Yes
No
Blood Disorders :
*
Yes
No
Cancer :
*
Yes
No
Bleeding Problems :
*
Yes
No
Chest Pains :
*
Yes
No
Colitis :
*
Yes
No
Depression :
*
Yes
No
Diabetes :
*
Yes
No
Ear Problems :
*
Yes
No
Eye Problems :
*
Yes
No
Epilepsy :
*
Yes
No
Heart Problems :
*
Yes
No
High Blood Pressure :
*
Yes
No
Hepatitis :
*
Yes
No
Seizures :
*
Yes
No
Irregular Heartbeat :
*
Yes
No
Any psychiatric conditions :
*
Yes
No
Migraine Headaches :
*
Yes
No
Nose/Throat Problems :
*
Yes
No
Pneumonia :
*
Yes
No
Shortness of Breath :
*
Yes
No
Rheumatic Fever :
*
Yes
No
Stomach Problems :
*
Yes
No
Transfusion :
*
Yes
No
Thyroid Problems :
*
Yes
No
Stroke :
*
Yes
No
For Women Only
Do you take birth control pills or any hormone replacement medication or patches? :
*
Yes
No
Are you pregnant ? :
*
Yes
No
(Pregnant women must take a pregnancy test before departure as most pregnancies can disrupt surgery)
Medical History
In the past 18 months, have you been hospitalized, had surgery or received medical treatment, pregnancy delivery, or ambulatory surgery :
*
ํYes
No
What was your date of surgery? :
*
What was your reason for surgery? :
*
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Testimonial
Contact Us
Sex Reassignment Surgery
Breast Augmentation
Facial Feminization Surgery
SRS & FFS Price
Blog Page
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