Skip to main content

facebook
linkedin
youtube
instagram

Education
No Stress Process
Testimonials
CALL NOW
ENQUIRE

Hit enter to search or ESC to close

search

Home
Surgery
Dental
Pricing
Hotels
Retreats
Get Started

search

Home
Surgery
Dental
Pricing
Hotels
Retreats
Get Started

Surgical Evaluation Form

Please complete this confidential form for your FREE Surgical Assessment from one of our board-certified Plastic & Reconstructive Surgeons.

A false declaration may result in the rejection of surgery by the surgeon at the time of consultation after your arrival. Diabetes may affect and delay the healing and scar tissue of the skin, resulting in additional medical attention and hospitalization at additional cost to you, the patient.

Please note that a confirmed treatment plan can only be provided when you are examined by the Surgeon. All quotations provided are estimated costs of the procedure requested. All estimates given are subject to change.

Assessment details

Surgical Medical Form

"*" indicates required fields

Full Name (As Per Passport)*

Email*

Re Enter Email*

Phone Number*

Current Address*

Street Address City State Country

Personal

Birth Date*

DD slash MM slash YYYY

Gender

Body Weight (In Kg's)*

Height (In CM)*

Nationality*

Preferred Language*

Emergency Contact Person*

Relation To You*

Emergency Contact Phone Number*

Emergency Contact Email*

Emergency Contact Address*

Street Address City State Country

What Procedures Do You Require? You may select more than one.**

Breast Augmentation

Breast Lift

Breast Reduction

Mummy Makeover

Tummy Tuck

Gastric Sleeve

Liposuction

Thigh Lift

Arm Lift

Face Lift

Eyelid Surgery

Nose Surgery

Ear Surgery

What Results Do You Want To Achieve?*

Have you previously had cosmetic surgery?*

Yes

No

Please give details of your Surgery including year.*

Do You Have Any Questions For The Surgeon?

Diabetes or blood sugar problems?*

Yes

No

Please clarify diabetes / blood sugar problems*

Thyroid problems?*

Yes

No

Please clarify thyroid problems*

Heart problems?*

Yes

No

Please clarify heart problems*

Lung problems?*

Yes

No

Please clarify lung problems*

Blood pressure problems?*

Yes

No

Please clarify blood pressure problems*

Kidney or liver problems?*

Yes

No

Please clarify Kidney / Liver problems**

Blood disorders?*

Yes

No

Previous/current history of cancer*

Yes

No

HIV or AIDS?*

Yes

No

Nervous breakdowns/Depression?*

Yes

No

Neurological problems?*

Yes

No

Anaesthesia problems?*

Yes

No

If you answered "Yes" to the above, please specify the Anaesthesia problem

Do you suffer from Sleep Apnea? (Breathing stops for a period of time during sleep)*

Yes

No

If you answered "Yes" to the above, please specify the Sleeping problem

Have you ever had a Stroke or Transient Ischaemic Attack (TIA)?*

Yes

No

Have you have had any medical conditions not mentioned above*

Yes

No

If you answered "Yes" to the above, please specify the medical condition

Are You Female And Requiring Breast Surgery and/or Tummy Tuck Surgery?*

Yes

No

Are You Currently Pregnant?*

Yes

No

Have You Undergone Any Surgical Means Of Birth Control? E.g. Tubal Ligation*

Yes

No

How Many Children Have You Given Birth To?

How Old is Your Youngest Child?

Are You Planning Any More Pregnancies?*

Yes

No

When Did You Last Deliver A Baby?

When Did You Last Breastfeed?*

Do Your Breasts Still Have Milk At This Time?*

Yes

No

Do You Take Birth Control Pills, Hormone Replacement Medication Or Wear A Hormone Patch?*

Yes

No

Have you been hospitalized, had surgery or received medical care within the past 5 years (including cosmetic surgery)?*

Yes

No

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

Yes

No

If you answered "Yes" to the above, please specify.

Do you have difficulty with healing or scarring?*

Yes

No

If you answered "Yes" to the above, please specify.

Do you have any allergies to food, drugs etc?*

Yes

No

If you answered "Yes" to the above, please specify.

List all medications you currently take and dosage you take for each.*

List all vitamins or food/nutritional supplements you currently take and dosage.*

Have you ever taken a MAO inhibitor such as Nardil, Marplan or Parnate?*

Yes

No

Have you ever taken Daily Coumadin, Daily Heparin or Daily Aspirin?*

Yes

No

Do You Smoke?*

Yes

No

How Many Cigarettes Do You Smoke Per Day?

Do You Drink Alcohol?*

Yes

No

How Many Alcoholic Beverages Do You Consume Per Week?

How did you hear about us?*

Is there any other information that you would like to share with us

Consent

I declare that I have truthfully completed the entirety of this form and that I have not made any purposeful omissions.

CAPTCHA

Δ

How To Take Your Surgery Assessment Photos

Arm Procedures

4 PHOTOS ARE REQUIRED FOR ARM PROCEDURES Front Right Arm, Front Left Arm, Back Right Arm, Back Left Arm

DO Take photos on a clear, uncluttered background
DO Make sure your photos are crisp and clear, blurry photos will not be accepted
DO Try to have someone else take your photo if possible , self-taken photos can be distorted

DON’T Take group photos
DON’T Take photos in a darkly lit room or shadow your body
DON’T Distort your body, follow the pictured instructions below

*Photos must be minimum of 150k in size and a maximum of 2000k in size your photos like your all information is kept strictly confidential and will only be seen by your consultant and surgeon.

Arm Procedure - Front - Medi Makeovers

View Larger

Front

Arm Procedure - Front - Medi Makeovers

Arm Procedure - Left side - Medi Makeovers

View Larger

Left side

Arm Procedure - Left side - Medi Makeovers

Arm Procedure - Left Side - Medi Makeovers

View Larger

Left Side

Arm Procedure - Left Side - Medi Makeovers

Arm Procedure - Right Side - Medi Makeovers

View Larger

Right Side

Arm Procedure - Right Side - Medi Makeovers

Tummy Procedures

6 PHOTOS ARE REQUIRED FOR STOMACH PROCEDURES Front, Right Side, Left Side, Backside, Leaning Left, Leaning Right KEEP YOUR HANDS AWAY FROM THE AREA – THOUGH, DO NOT STRETCH YOUR ARMS AWAY

DO Take photos on a clear, uncluttered background
DO Make sure your photos are crisp and clear, blurry photos will not be accepted
DO Try to have someone else take your photo if possible , self-taken photos can be distorted

DON’T Take group photos
DON’T Take photos in a darkly lit room or shadow your body
DON’T Distort your body, follow the pictured instructions below

*Photos must be minimum of 150k in size and a maximum of 2000k in size your photos like your all information is kept strictly confidential and will only be seen by your consultant and surgeon.

Tummy Procedures - Front - Medi Makeovers

View Larger

Front

Tummy Procedures - Front - Medi Makeovers

Tummy Procedures - Front - Medi Makeovers

View Larger

Front

Tummy Procedures - Front - Medi Makeovers

Tummy Procedures - Front - Medi Makeovers

View Larger

Front

Tummy Procedures - Front - Medi Makeovers

Tummy Procedures - Front - Medi Makeovers

View Larger

Front

Tummy Procedures - Front - Medi Makeovers

Tummy Procedures - Front - Medi Makeovers

View Larger

Front

Tummy Procedures - Front - Medi Makeovers

Breast Procedures

3 PHOTOS ARE REQUIRED FOR BREAST PROCEDURES Front, Right Side, Left Side KEEP YOUR ARMS BY YOUR SIDES

DO Take photos on a clear, uncluttered background
DO Make sure your photos are crisp and clear, blurry photos will not be accepted
DO Try to have someone else take your photo if possible, self-taken photos can be distorted

DON’T Take group photos
DON’T Take photos in a darkly lit room or shadow your body
DON’T Distort your body, follow the pictured instructions below

*Photos must be minimum of 150k in size and a maximum of 2000k in size your photos like your all information is kept strictly confidential and will only be seen by your consultant and surgeon.

Breast Procedures - Front - Medi Makeovers

View Larger

Front

Breast Procedures - Front - Medi Makeovers

Breast Procedures - Left side - Medi Makeovers

View Larger

Left side

Breast Procedures - Left side - Medi Makeovers

Breast Procedures - Right side - Medi Makeovers

View Larger

Right Side

Breast Procedures - Right side - Medi Makeovers

Face Procedures

5 PHOTOS ARE REQUIRED FOR FACE PROCEDURES Front, Right Side, Left Side, 45 Degree Right, 45 Degree Left KEEP YOUR HAIR OFF YOUR FACE + NECK, PUT YOUR HAIR UP IF NEED BE.

DO Take photos on a clear, uncluttered background
DO Make sure your photos are crisp and clear, blurry photos will not be accepted
DO Try to have someone else take your photo if possible , self-taken photos can be distorted

DON’T Take group photos
DON’T Take photos in a darkly lit room or shadow your body
DON’T Distort your body, follow the pictured instructions below

*Photos must be minimum of 150k in size and a maximum of 2000k in size your photos like your all information is kept strictly confidential and will only be seen by your consultant and surgeon.

Face Procedures - Cosmetic Surgery - Medi Makeovers

View Larger

Front

Face Procedures - Cosmetic Surgery - Medi Makeovers

Face Procedures - Cosmetic Surgery - Medi Makeovers

View Larger

Front

Face Procedures - Cosmetic Surgery - Medi Makeovers

Face Procedures - Cosmetic Surgery - Medi Makeovers

View Larger

Front

Front

Face Procedures - Cosmetic Surgery - Medi Makeovers

View Larger

Front

Face Procedures - Cosmetic Surgery - Medi Makeovers

Face Procedures - Cosmetic Surgery - Medi Makeovers

View Larger

Front

Face Procedures - Cosmetic Surgery - Medi Makeovers

Nose Procedures

7 PHOTOS ARE REQUIRED FOR NOSE PROCEDURES Front, Right Side, Left Side, 45 Degree Right, 45 Degree Left, Looking Up, Looking Down KEEP YOUR HAIR OFF YOUR FACE + NECK, PUT YOUR HAIR UP IF NEED BE.

DO Take photos on a clear, uncluttered background
DO Make sure your photos are crisp and clear, blurry photos will not be accepted
DO Try to have someone else take your photo if possible , self-taken photos can be distorted

DON’T Take group photos
DON’T Take photos in a darkly lit room or shadow your body
DON’T Distort your body, follow the pictured instructions below

*Photos must be minimum of 150k in size and a maximum of 2000k in size your photos like your all information is kept strictly confidential and will only be seen by your consultant and surgeon.

Face Procedures - Cosmetic Surgery - Medi Makeovers

View Larger

Front

Face Procedures - Cosmetic Surgery - Medi Makeovers

Face Procedures - Cosmetic Surgery - Medi Makeovers

View Larger

Front

Face Procedures - Cosmetic Surgery - Medi Makeovers

Face Procedures - Cosmetic Surgery - Medi Makeovers

View Larger

Front

Front

Face Procedures - Cosmetic Surgery - Medi Makeovers

View Larger

Front

Face Procedures - Cosmetic Surgery - Medi Makeovers

Face Procedures - Cosmetic Surgery - Medi Makeovers

View Larger

Front

Face Procedures - Cosmetic Surgery - Medi Makeovers

Nose Procedures - Cosmetic Surgery - Medi Makeovers

View Larger

Front

Nose Procedures - Cosmetic Surgery - Medi Makeovers

Nose Procedures - Cosmetic Surgery - Medi Makeovers

View Larger

Front

Front

Thigh Procedures

4 PHOTOS ARE REQUIRED FOR THIGH PROCEDURES Front, Right Side, Left Side, Backside

DO Take photos on a clear, uncluttered background
DO Make sure your photos are crisp and clear, blurry photos will not be accepted
DO Try to have someone else take your photo if possible , self-taken photos can be distorted

DON’T Take group photos
DON’T Take photos in a darkly lit room or shadow your body
DON’T Distort your body, follow the pictured instructions below

*Photos must be minimum of 150k in size and a maximum of 2000k in size your photos like your all information is kept strictly confidential and will only be seen by your consultant and surgeon.

thigh lift surgery

View Larger

Front

Front

thigh lift surgery

View Larger

Right Side

Right Side

thigh lift surgery

View Larger

Left Side

Left Side

thigh reduction surgery

View Larger

Backside

Backside

Are You Ready?

Then join us now on your journey to the new you!

Medi Makeovers is 100% Australian Owned + Operated and committed to offering you the best medical travel options in Thailand.

There are inherent risks associated with all types of surgery, no matter where they are performed, so it is imperative to do your homework before deciding on any procedure

Navigation

Surgery

Dental

Client Success

Our Process

Contact

T: 0416 109 417

E: enquiries@medimakeovers.com

© 2023 Medi Makeovers

Terms & Conditions

You may not copy, publish or use any of the content on this site without written permission from Medi Makeovers.

Disclaimer: Medi Makeovers is a medical tourism facilitator and in providing any medical information to its clients and prospective clients relies on medical, surgical and other recommendations supplied by the hospitals and clinics in Thailand that Medi Makeovers is accredited with. Medi Makeovers provides this information to its clients and prospective clients on behalf of these hospitals and clinics and in good faith, however, this must not be construed as Medi Makeovers offering or providing medical advice. Regardless of the wording, no information expressed in this website is to be interpreted as Medi Makeovers or its personnel offering or providing medical advice or recommendations. All pricing is in Thai Baht and all other currencies shown are the estimated currency conversion. You must check the currency conversion closer to your procedure date as you will pay for your procedure in Thai Baht.